147.Paleri, V., et al.
Applicability of the adult comorbidity evaluation - 27 and the Charlson indexes to assess
comorbidity by notes extraction in a cohort of United Kingdom patients with head and neck cancer: a
retrospective study. J Laryngol Otol, 2002. 116: 200.

361.Simon, J. Ectopia Vesicae
(Absence of the anterior walls of the Bladder and the pubic abdominal parietes) Operation for
directing the orifices of the ureteres into the rectum, temporary success) JAMA 1911. 1911: 398. [No
abstract available].

548.Aaronson, N.K., et al. The
European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for
use in international clinical trials in oncology. J Natl Cancer Inst, 1993. 85: 365.

1.INTRODUCTION

1.1.Aims and scope

The European Association of Urology (EAU) Guidelines Panel for Muscle-invasive and
Metastatic Bladder Cancer (MIBC) have prepared these guidelines to help urologists assess the
evidence-based management of MIBC and to incorporate guideline recommendations into their clinical
practice.

It must be emphasised that clinical guidelines present the best
evidence available to the experts but following guideline recommendations will not necessarily
result in the best outcome. Guidelines can never replace clinical expertise when making treatment
decisions for individual patients, but rather help to focus decisions - also taking personal values
and preferences/individual circumstances of patients into account. Guidelines are not mandates and
do not purport to be a legal standard of care.

1.2.Panel Composition

The EAU Guidelines Panel consists of an international multidisciplinary group of
clinicians, including urologists, oncologists, a pathologist and a radiologist.

1.3.Available publications

A quick reference document (Pocket Guidelines) is available, both in print and as
an app for iOS and Android devices. These are abridged versions which may require consultation
together with the full text version.

1.4.Publication history and summary of changes

1.4.1.Publication history

The EAU published its first guidelines on BC in 2000. This document covered both
NMIBC and MIBC. Since these conditions require different treatment strategies, it was decided to
give each condition its own guidelines, resulting in the first publication of the MIBC Guidelines in
2004. This 2019 document presents a limited update of the 2018 version.

1.4.2.Summary of changes

New relevant references have been identified through a structured assessment of the
literature and incorporated in the various chapters of the 2019 EAU MIBC Guidelines.

Key changes in the 2019 print are:

Section 6.3 Prognostic markers – this section was revised, to include new data. Based on the
current data, no recommendation can be provided.

Section 7.2 Neoadjuvant therapy – this section was revised and restructured. A new
recommendation was added.

7.2.4 Summary of evidence and guidelines for neoadjuvant therapy

Summary of evidence

LE

Currently immunotherapy with
checkpoint inhibitors is tested in phase II and III trials. First results are promising.

Recommendation

Strength
rating

Only offer
neoadjuvant immunotherapy to patients within a clinical trial setting.

Strong

New Section 7.4.7 – Impact of hospital and surgeon volume on treatment outcomes, has been
included. This section is based on the findings of a systematic review (SR) on ‘The impact of
the annual hospital and surgeon radical cystectomy volume for BC on peri-operative outcomes and
long-term oncological outcomes’ [5];

Section 7.6.2 External beam radiotherapy (EBRT) - this section was revised, to include new data.
The recommendations did not change.

Section 7.6.4 Multimodality bladder-preserving treatment - this section was revised, to include
new data. The recommendations did not change.

Section 7.7 Adjuvant therapy - this section was revised, to include new data. A new
recommendation was included.

7.7.3 Guideline for adjuvant therapy

Recommendation

Strength
rating

Offer immunotherapy
with a checkpoint inhibitor only in a clinical trial setting.

Strong

Section 7.8 Metastatic disease – this section was revised, to include new data, resulting in
changes to both the Summary of evidence and the recommendations.

7.8.11 Summary of evidence and guidelines for metastatic disease

Summary of evidence

LE

Post-chemotherapy surgery
after partial or complete response may contribute to long-term disease-free survival in
selected patients.

3

PD-1 inhibitor pembrolizumab
has been approved for patients with advanced or metastatic urothelial cancer ineligible for
cisplatin-based first-line chemotherapy based on the results of a phase II trial but use of
pembrolizumab is restricted to PD-L1 positive patients.

2a

PD-L1 inhibitor atezolizumab
has been approved for patients with advanced or metastatic urothelial cancer ineligible for
cisplatin-based first-line chemotherapy based on the results of a phase II trial but use of
atezolizumab is restricted to PD-L1 positive patients.

2a

Recommendations

Strength
rating

First-line treatment for cisplatin-eligible patients

Use
cisplatin-containing combination chemotherapy with GC, MVAC, preferably with G-CSF, HD-MVAC
with G-CSF or PCG.

Offer zoledronic acid
or denosumab for supportive treatment in case of bone metastases.

Weak

Only offer vinflunine
to patients for metastatic disease as second-line treatment if immunotherapy or combination
chemotherapy is not feasible. Alternatively, offer vinflunine as third- or subsequent
treatment line.

Figure 7.2: Flow chart for the management of metastatic urothelial cancer was adapted.

Section 7.9 Quality of life - this section was revised to include new data. However, the
recommendations did not change.

Summary of evidence

LE

Compared to non-cancer
controls, the diagnosis and treatment of bladder cancer has a negative impact on
health-related quality of life (HRQoL).

2a

2.METHODS

2.1.Data identification

For the 2019 MIBC Guidelines, new and relevant evidence has been identified,
collated and appraised through a structured assessment of the literature. A broad and comprehensive
literature search, covering all sections of the MIBC Guideline was performed. The search was limited
to English language publications. Databases searched included Medline, EMBASE and the Cochrane
Libraries, covering a time frame between June 2nd 2017 and June
1st, 2018. A total of 1,676 unique records were identified,
retrieved and screened for relevance. Forty-four new publications have been included in the 2019
print. A detailed search strategy is available online: http://uroweb.org/guideline/bladder-cancer-muscle-invasive-and-metastatic/?type=appendices-publications.

For each recommendation within the guidelines there is an accompanying online
strength rating form, the basis of which is a modified GRADE methodology [6,7]
which addresses a number of key elements namely:

the overall quality of the evidence which exists for the recommendation, references used in this
text are graded according to a classification system modified from the Oxford Centre for
Evidence-Based Medicine Levels of Evidence [8];

the magnitude of the effect (individual or combined effects);

the certainty of the results (precision, consistency, heterogeneity and other statistical or
study related factors);

the balance between desirable and undesirable outcomes;

the impact of patient values and preferences on the intervention;

the certainty of those patient values and preferences.

These key elements are the basis which panels use to define the strength rating of
each recommendation. The strength of each recommendation is represented by the words ‘strong’ or
‘weak’ [9].
The strength of each recommendation is determined by the balance between desirable and undesirable
consequences of alternative management strategies, the quality of the evidence (including certainty
of estimates), and nature and variability of patient values and preferences. The strength rating
forms will be available online.

Additional information can be found in the general Methodology
section of this print, and online at the EAU website; http://www.uroweb.org/guideline/.
A list of Associations endorsing the EAU Guidelines can also be viewed online at the above address.

2.2.Peer-review

The 2019 MIBC Guidelines have not been peer reviewed.

2.2.1.Lay review

Post publication, the 2018 MIBC Guidelines were shared with seven patients treated
for MIBC. Their comments were requested, but not limited to:

the overall tone of the guidelines content;

any missing information;

any information considered incorrect;

any information which is not presented in a clear fashion;

any text which is considered redundant and should be omitted;

any text section that should be more detailed.

Common comments across reviewers:

In general, the overall tone of the text was considered informational and instructive, but the
language used obviously targets medical professionals, which make certain parts of the text
difficult to understand for lay persons. The use of the many abbreviations is considered an
additional hindrance, as are the methodological elements. In case the EAU are considering
producing a lay version of this text, the language needs to be adapted and clear instructions
are to be provided.

It is difficult for lay reviewers to comment on what may be omitted since, in their opinion,
they lack the expertise.

Some sections, such as ‘Recurrent disease’ and ‘Markers’ denote areas where less evidence is
available. Consequently, the available data is less systematically presented which makes these
sections more difficult to understand.

There is an interest whether screening for BC is a consideration.

In particular ‘follow up’, ‘quality of life’ and ‘survivorship aspects’ should be elaborated on;
providing additional information on what may be expected after treatment is considered very
helpful for patients and their families. Also lifestyle elements would be of relevance (healthy
living, “what to do to prevent cancer”). For this section, in particular, involvement of
patients in the text development was considered missing. Transparency about the process of
patient involvement in guidelines development was considered most relevant.

The MIBC Guidelines Panel is most grateful for the unique insights and guidance
provided by the lay reviewers.

2.3.Future goals

Topics considered for inclusion in the 2020 update of the MIBC Guidelines:

a SR on ‘What is the importance of urothelial and non-urothelial histological variants of BC in
predicting oncological outcomes in patients with muscle-invasive and metastatic BC?’ [10];

development of a diagnostic pathway for the assessment of visible and non-visible haematuria;

inclusion of data based on the EAU-ESMO Consensus Conference on Urothelial Carcinoma;

participation in developing strategies to ensure meaningful participation of patients in the
development and implementation of the MIBC Guidelines.

3.EPIDEMIOLOGY, AETIOLOGY AND PATHOLOGY

3.1.Epidemiology

Bladder cancer (BC) is the 7th most commonly
diagnosed cancer in males, whilst it drops to 11th when both
genders are considered [11].
The worldwide age-standardised incidence rate (per 100,000 person/years) is 9.0 for men and 2.2 for
women [11].
In the European Union, the age-standardised incidence rate is 19.1 for men and 4.0 for women [8].
In Europe, the highest age-standardised incidence rate has been reported in Belgium (31 in men and
6.2 in women) and the lowest in Finland (18.1 in men and 4.3 in women) [8,11].

Worldwide, the BC age-standardised mortality rate (per 100,000
person/years) was 3.2 for men vs. 0.9 for women in 2012 [8,11].
Bladder cancer incidence and mortality rates vary across countries due to differences in risk
factors, detection and diagnostic practices, and availability of treatments. The variations are,
however, also partly caused by the different methodologies used in the studies and the quality of
data collection [12,13].

The incidence and mortality of BC has decreased in some
registries, possibly reflecting the decreased impact of causative agents [13,14].

Approximately 75% of patients with BC present with disease
confined to the mucosa (stage Ta, carcinoma in situ [CIS]) or
submucosa (stage T1). In younger patients (< 40 years) this percentage is even higher [15].
Patients with TaT1 and CIS have a high prevalence due to long-term survival in many cases and lower
risk of cancer-specific mortality (CSM) compared to T2-4 tumours [8,12,16].

3.2.Aetiology

3.2.1.Tobacco smoking

Tobacco smoking is the most well-established risk factor for BC, causing 50-65% of
male cases and 20-30% of female cases [17].
A causal relationship has been established between exposure to tobacco and cancer in studies in
which chance, bias and confounding can be discounted with reasonable confidence [18].

The incidence of BC is directly related to the duration of
smoking and the number of cigarettes smoked per day [19].
A meta-analysis looked at 216 observational studies on cigarette smoking and cancer published
between 1961 and 2003, and the pooled risk estimates for BC demonstrated a significant association
for both current and former smokers [20].
Recently, an increase in risk estimates for current smokers relative to never smokers has been
described suggesting this could be due to changes in cigarette composition [18].
An immediate decrease in the risk of BC was observed in those who stopped smoking. The reduction was
about 40% within one to four years of quitting smoking and 60% after 25 years of cessation [19].
Encouraging people to stop smoking would result in the incidence of BC decreasing equally in men and
women [17].

3.2.2.Occupational exposure to chemicals

Occupational exposure is the second most important risk factor for BC. Work-related
cases accounted for 20-25% of all BC cases in several series and it is likely to occur in
occupations in which dyes, rubbers, textiles, paints, leathers, and chemicals are used [21].
The risk of BC due to occupational exposure to carcinogenic aromatic amines is significantly greater
after ten years or more of exposure; the mean latency period usually exceeds 30 years [22,23].
Population-based studies established the occupational attribution for BC in men to be 7.1%, while no
such attribution was discernible for women [12,24].

3.2.3.Radiotherapy

Increased rates of secondary bladder malignancies have been reported after
external-beam radiotherapy (EBRT) for gynaecological malignancies, with relative risks of 2-4 [25].
In a population-based cohort study, the standardised incidence ratios for BC developing after
radical prostatectomy (RP), EBRT, brachytherapy, and EBRT-brachytherapy were 0.99, 1.42, 1.10, and
1.39, respectively, in comparison with the general U.S. population [26].

It has recently been proposed that patients who have received
radiotherapy (RT) for prostate cancer with modern modalities such as intensity-modulated
radiotherapy (IMRT) may have lower rates of in-field bladder- and rectal secondary malignancies [27].
Nevertheless, since longer follow-up data are not yet available, and as BC requires a long period to
develop, patients treated with radiation and with a long life-expectancy are at a higher risk of
developing BC [27].

3.2.4.Dietary factors

Several dietary factors have been related to BC; however, the links remain
controversial. The European Prospective Investigation into Cancer and Nutrition (EPIC) study is an
on-going multicentre cohort study designed to examine the association between diet, lifestyle,
environmental factors and cancer. They found no links between BC and fluid intake, red meat,
vegetable and fruit consumption and only recently an inverse association between dietary intake of
flavonoids and lignans and the risk of aggressive BC tumours has been described [28].

3.2.5.Bladder schistosomiasis and chronic urinary tract infection

Bladder schistosomiasis (bilharzia) is the second most common parasitic infection
after malaria, with about 600 million people exposed to infection in Africa, Asia, South America,
and the Caribbean [29].
There is a well-established relationship between schistosomiasis and urothelial carcinoma (UC) of
the bladder, which can progress to squamous cell carcinoma (SCC), however, better control of the
disease is decreasing the incidence of SCC of the bladder in endemic zones such as Egypt [30,31].

Similarly, invasive SCC has been linked to the presence of
chronic urinary tract infection (UTI) distinct from schistosomiasis. A direct association between BC
and UTIs has been observed in several case-control studies, which have reported a two-fold increased
risk of BC in patients with recurrent UTIs in some series. However, some of these results may be
attributed to recall bias [32].

3.2.6.Gender

Although men are more likely to develop BC than women, women present with more
advanced disease and have worse survival rates. A meta-analysis including nearly 28,000 patients
shows that female gender was associated with a worse survival outcome (hazard ratio [HR]: 1.20; 95%
CI: 1.09-1.32) compared to male gender after radical cystectomy (RC) [33].
This finding had already been presented in a descriptive Nation-Wide Analysis based on 27,773
Austrian patients. After their analysis the authors found that cancer-specific-survival (CSS) was
identical for pT1-tumours in both sexes, while women had a worse CSS in both age cohorts (< 70
years and > 70 years) with higher tumour stages [34].
However, this higher mortality is questionable once both genders receive the same therapy. In a
population-based study from the Ontario Cancer Registry analysing all patients with BC treated with
cystectomy or radical RT between 1994 and 2008, no differences in overall survival (OS), mortality
and outcomes were found between males and females following radical therapy [35].

A population-based study from the MarketScan databases suggests
that a possible reason for worse survival in the female population may be that women experienced
longer delays in diagnosis than men, as the differential diagnosis in women includes diseases that
are more prevalent than BC [36].

Furthermore, differences in the gender prevalence of BC may be
due to other factors besides tobacco and chemical exposure. In a large prospective cohort study,
post-menopausal status was associated with an increase in BC risk, even after adjustment for smoking
status. This result suggests that the differences in oestrogen and androgen levels between men and
women may be responsible for some of the difference in the gender prevalence of BC [37-39].

3.2.7.Genetic factors

There is growing evidence that genetic susceptibility factors and family
association may influence the incidence of BC. A recent population-based study of cancer risk in
relatives and spouses of UC patients showed an increased risk for first- and second-degree
relatives, and suggests genetic or environmental roots independent of smoking-related behaviour [40].
Shared environmental exposure was recognised as a potentially confounding factor [41].
Recent studies detected genetic susceptibility with independent loci, which are associated with BC
risk [42].

3.2.8.Summary of evidence and guidelines for epidemiology and risk factors

Summary of evidence

LE

Worldwide, bladder cancer is
the 11th most commonly diagnosed cancer.

2a

Several risk factors
associated with bladder cancer diagnosis have been identified.

3

Active and passive tobacco
smoking continues to be the main risk factor, while the exposure-related incidence is
decreasing.

2a

The increased risk of
developing bladder cancer in patients undergoing external-beam radiotherapy (EBRT),
brachytherapy, or a combination of EBRT and brachytherapy, must be considered during patient
follow-up. As bladder cancer requires time to develop, patients treated with radiation at a
young age are at the greatest risk and should be followed up closely.

3

Recommendations

Strength
rating

Council patients to
stop active and avoid passive smoking.

Strong

Inform workers in
potentially hazardous workplaces of the potential carcinogenic effects of a number of
recognised substances, including duration of exposure, and latency periods. Protective
measures are recommended.

Strong

3.3.Pathology

3.3.1.Handling of transurethral resection and cystectomy specimens

In transurethral resection (TUR), a snap frozen specimen from the tumour and normal
looking bladder wall should be taken, if possible. Specimens should be taken from the superficial
and deep areas of the tumour and sent to the pathology laboratory separately, in case the outcome
will impact on treatment decisions. If random biopsies of the flat mucosa are taken, each biopsy
specimen of the flat mucosa should also be submitted separately.

In RC, bladder fixation must be carried out as soon as possible.
The pathologist must open the specimen from the urethra to the bladder dome and fix the specimen. In
some circumstances this procedure can also be performed by the urologist. In a female cystectomy
specimen, the length of the urethral segment removed en bloc
with the specimen should be checked, preferably by the urological surgeon [45].

Specimen handling should follow the general rules as published by a collaborative
group of pathologists and urologists [46,47].
It must be stressed that it may be very difficult to confirm the presence of a neoplastic lesion
using gross examination of the cystectomy specimen after TUR or chemotherapy, so the entire
retracted or ulcerated area should be included.

It is compulsory to study the urethra, the ureters, the prostate
in men and the radial margins [48].
In urethra-sparing cystectomy; the level of urethral dissection, completeness of the prostate,
specifically at the apex (in men), and the inclusion of the entire bladder neck and amount of
adjacent urethra, uterus and vaginal top (in women) should be inked and documented.

All lymph node (LN) specimens should be provided in their totality, in clearly
labelled containers. In case of doubt, or adipose differentiation of the LN, the entire specimen is
to be included. Lymph nodes should be counted and measured on slides, capsular extension and
percentage of LN invasion should be reported as well as vascular embols [49,50].
In the case of metastatic spread in the perivesical fat without real LN structures (capsule,
subcapsular sinus), this localisation should nevertheless be considered as N+.

Positive margins in the peripelvic fat tissue (soft tissue
margins), should be inked by the pathologist for evaluation. Positive margins decrease CSS in cases
of pN0M0 UCs [51].

In rare cases, fresh frozen sections may be helpful to determine
treatment strategy. The reliability of fresh frozen sections of obturator LNs was confirmed in a
study, but further research is needed to confirm these results [52].

3.3.2.Pathology of muscle-invasive bladder cancer

All MIBC cases are high-grade UCs. For this reason, no prognostic information can
be provided by grading MIBC [53].
However, identification of some morphological subtypes may be important for prognostic reasons and
treatment decisions [54,55].
Recently, an update of the World Health Organization (WHO) grading was published [56],
however, the data presented in these guidelines are based on the 2004 WHO classification [57].

3.3.3.Guidelines for the assessment of tumour specimens

Record the depth of
invasion (categories pT2a and pT2b, pT3a and pT3b or pT4).

Strong

Record margins with
special attention paid to the radial margin, prostate, ureter, urethra and peritoneal fat
and uterus and vaginal top.

Record the total
number of lymph nodes (LNs), the number of positive LNs and extranodal spread.

Record lymphatic or
blood vessel invasion and extranodal extension.

Record the presence
of carcinoma in situ.

4.STAGING AND CLASSIFICATION SYSTEMS

4.1.Pathological staging

For staging, the Tumour, Node, Metastasis (TNM) Classification (2017, 8th edition) is recommended [62].
Blood and lymphatic vessel invasion and LN infiltration have an independent prognostic significance
[63,64].
It seems that the pN category is closely related to the number of LNs studied by the pathologist [62].

4.2.Tumour, node, metastasis classification

The TNM classification of malignant tumours is the method most widely used to
classify the extent of cancer spread [54-56,62,65]
(Table 4.1).

5.DIAGNOSTIC EVALUATION

5.1.Primary diagnosis

5.1.1.Symptoms

Painless haematuria is the most common presenting complaint. Other clinical signs
include urgency, dysuria, increased frequency, and in more advanced tumours, pelvic pain and
symptoms related to urinary tract obstruction.

5.1.2.Physical examination

Physical examination should include rectal and vaginal bimanual palpation. A
palpable pelvic mass can be found in patients with locally advanced tumours. In addition, bimanual
examination under anaesthesia should be carried out before and after transurethral resection of the
bladder (TURB), to assess whether there is a palpable mass or if the tumour is fixed to the pelvic
wall [66,67].
However, considering the discrepancy between bimanual examination and pT stage after cystectomy (11%
clinical overstaging and 31% clinical understaging), some caution is suggested with the
interpretation of bimanual examination [68].

5.1.3.Bladder imaging

Patients with a bladder mass identified by any diagnostic imaging technique should
undergo cystoscopy, biopsy and/or resection for histopathological diagnosis and staging.

5.1.4.Urinary cytology

Examination of voided urine or bladder washings for exfoliated cancer cells has
high sensitivity in high-grade tumours (LE: 3) and is a useful indicator in cases of high-grade
malignancy or CIS.

However, positive urinary cytology may originate from a
urothelial tumour located anywhere in the urinary tract. Evaluation of cytology specimens can be
hampered by low cellular yield, UTIs, stones or intravesical instillations, but for experienced
readers, specificity exceeds 90% [69,70]
(LE: 2b). However, negative cytology does not exclude a tumour. There is no known urinary marker
specific for the diagnosis of invasive BC [71].

A standardised reporting system redefining urinary cytology diagnostic categories
was published in 2016 by the Paris Working Group [72]:

adequacy of urine specimens (Adequacy);

negative for high-grade UC (Negative);

atypical urothelial cells (AUC);

suspicious for high-grade UC (Suspicious);

high-grade UC (HGUC);

low-grade urothelial neoplasia (LGUN).

5.1.5.Cystoscopy

Ultimately, the diagnosis of BC is made by cystoscopy and histological evaluation
of resected tissue. If a bladder tumour has been visualised unequivocally by imaging studies such as
computed tomography (CT), magnetic resonance imaging (MRI), or ultrasound (US), diagnostic
cystoscopy may be omitted, and the patient can proceed directly to TURB for histological diagnosis
and resection. Currently, there is no evidence for the role of photodynamic diagnosis (PDD) in the
standard diagnosis of invasive BC.

A careful description of the cystoscopic findings is necessary.
This should include documentation of the site, size, number, and appearance (papillary or solid) of
the tumours, as well as a description of any mucosal abnormalities [73].
The use of a bladder diagram is recommended.

The use of PDD could be considered if a T1 high-grade tumour is
present, to identify associated CIS. Presence of CIS may lead to a modified treatment plan (see
Section 7.1). Photodynamic diagnosis is highly sensitive for the detection of CIS and in experienced
hands the rate of false-positive results may be similar to that with regular white-light cystoscopy
[64,74].

5.1.6.Transurethral resection of invasive bladder tumours

The goal of TURB is to enable histopathological diagnosis and staging, which
requires the inclusion of bladder muscle in the resection biopsies.

The strategy of resection depends on the size of the lesion.
Small tumours (< 1 cm in diameter) can be resected en bloc,
where the specimen contains the complete tumour plus a part of the underlying bladder wall including
muscle. Larger tumours need to be resected separately in parts, which includes the exophytic part of
the tumour, the underlying bladder wall with the detrusor muscle, and the edges of the resection
area. At least the deeper part of the resection specimen must be referred to the pathologist in a
separate labelled container to enable them to make a correct diagnosis. In cases in which RT is
considered and CIS is to be excluded, PDD can be used [75].

The involvement of the prostatic urethra and ducts in men with
bladder tumours has been reported. The exact risk is not known, but it seems to be higher if the
tumour is located on the trigone or bladder neck, with concomitant bladder CIS, and in the case of
multiple tumours [76,77]
(LE: 3). Involvement of the prostatic urethra can be determined either at the time of primary TURB
or by frozen section during the cystoprostatectomy procedure. A frozen section has a higher
negative-predictive value and is more accurate [78-80].

5.1.7.Second resection

In the case of high-grade non-muscle-infiltrative tumour, residual disease is
observed in 33-53% of patients [81-87].
In order to reduce the risk of understaging [82,83],
a second TURB resection is often required to determine subsequent treatment strategy.

Diagnosis of a urethral tumour before cystectomy or positive
urethral frozen section leads to urethrectomy and therefore excludes neobladder reconstruction. If
indicated, in males, urethral frozen section has to be performed on the cystoprostatectomy specimen
just below the verumontanum bladder neck, and on the inferior limits of the bladder neck for
females.

5.1.9.Summary of evidence and guidelines for the primary assessment of presumably invasive bladder tumours

(For general information on the assessment of bladder tumours, see EAU
Guidelines on Non-muscle-invasive Bladder Cancer [2]).

Summary of evidence

LE

Currently, treatment decisions
cannot be based on molecular markers.

3

Recommendations

Strength
rating

Describe all
macroscopic features of the tumour (site, size, number and appearance) and mucosal
abnormalities during cystoscopy. Use a bladder diagram.

Strong

Take a biopsy of the
prostatic urethra in cases of bladder neck tumour, when bladder carcinoma in situ is present or suspected, when there is
positive cytology without evidence of tumour in the bladder, or when abnormalities of the
prostatic urethra are visible.

Strong

Take a biopsy at the
time of the second resection, if no biopsy was taken during the initial procedure.

Strong

In women undergoing
subsequent orthotopic neobladder construction, obtain procedural information (including
histological evaluation) of the bladder neck and urethral margin, either prior to, or at the
time of cystoscopy.

Strong

Specify the grade,
depth of tumour invasion, and whether the lamina propria and muscle tissue are present in
the specimen in the pathology report.

Strong

5.2.Imaging for staging of MIBC

The treatment and prognosis of MIBC is determined by tumour stage and grade [92,93].
In clinical practice, CT and MRI are the imaging techniques used. The purpose of using imaging for
staging MIBC is to determine prognosis and provide information to assist treatment selection. Tumour
staging must be accurate to ensure that the correct choice of treatment is made. Imaging parameters
required for staging MIBC are:

5.2.1.Local staging of MIBC

Both CT and MRI may be used for assessment of local invasion, but they are unable
to accurately diagnose microscopic invasion of perivesical fat (T2 vs. T3a) [94].
The principal aim of CT and MRI is to detect T3b disease, or higher.

5.2.1.1.MRI for local staging of invasive bladder
cancer

Magnetic resonance imaging has superior soft tissue contrast resolution compared
with CT, but poorer spatial resolution. In studies performed before the availability of
multidetector CT, MRI was reported as more accurate in local assessment. The accuracy of MRI for
primary tumour staging varies from 73% to 96% (mean 85%). A meta-analysis of seventeen studies
showed a 91% sensitivity and 96% specificity for 3.0-T device MRI combined with diffusion-weighted
imaging (DWI) to differentiate < T1 tumours from > T2 tumours before surgery [95].
These values were 10-33% (mean 19%) higher than those obtained with CT [96].
Dynamic contrast-enhanced (DCE) MRI may help to differentiate bladder tumour from surrounding
tissues, in particular in patients where organ-preserving cystectomy is considered. Magnetic
resonance imaging may evaluate post-biopsy reaction, because enhancement of the tumour occurs
earlier than that of the normal bladder wall due to neovascularisation [97-99].

In 2006, a link was established between the use of gadolinium-based contrast agents
and nephrogenic systemic fibrosis (NSF), which may result in fatal or severely debilitating systemic
fibrosis. Patients with impaired renal function are at risk of developing NSF and non-ionic linear
gadolinium-based contrast agents should be avoided (gadodiamide, gadopentetate dimeglumine and
gadoversetamide). A stable macrocyclic contrast agent should be used (gadobutrol, gadoterate
meglumine or gadoteridol). Contrast-enhanced CT using iodinated contrast media can be considered as
an alternative [100]
(LE: 4).

5.2.1.2.CT imaging for local staging
of MIBC

The advantages of CT include high spatial resolution, shorter acquisition time,
wider coverage in a single breath hold, and lower susceptibility to variable patient factors.
Computed tomography is unable to differentiate between stages Ta to T3a tumours, but it is useful
for detecting invasion into the perivesical fat (T3b) and adjacent organs. The accuracy of CT in
determining extravesical tumour extension varies from 55% to 92% [101]
and increases with more advanced disease [102].

5.2.2.Imaging of lymph nodes in MIBC

Assessment of LN metastases based solely on size is limited by the inability of
both CT and MRI to identify metastases in normal-sized or minimally enlarged nodes. The sensitivity
for detection of LN metastases is low (48-87%). Specificity is also low because nodal enlargement
may be due to benign disease. Overall, CT and MRI show similar results in the detection of LN
metastases in a variety of primary pelvic tumours [96,103-107].
Pelvic nodes > 8 mm and abdominal nodes > 10 mm in maximum short-axis diameter, detected by CT
or MRI, should be regarded as pathologically enlarged [108,109].

Positron emission tomography combined with CT is increasingly
being used in clinical practice and its exact role continues to be evaluated [110].

5.2.3.Upper urinary tract urothelial carcinoma

5.2.3.1.Computed tomography urography

Computed tomography urography has the highest diagnostic accuracy of the available
imaging techniques [111].
The sensitivity of CT urography for UTUC is 0.67-1.0 and specificity is 0.93-0.99 [112].

Rapid acquisition of thin sections allows high-resolution
isotropic images that can be viewed in multiple planes to assist with diagnosis without loss of
resolution. Epithelial “flat lesions” without mass effect or urothelial thickening are generally not
visible with CT.

The secondary sign of hydronephrosis is associated with advanced
disease and poor oncological outcome [113,114].
The presence of enlarged LNs is highly predictive of metastases in UTUC [115].

5.2.3.2.Magnetic resonance urography

Magnetic resonance urography is indicated in patients who cannot undergo CT
urography, usually when radiation or iodinated contrast media are contraindicated [116].
The sensitivity of MR urography is 0.75 after contrast injection for tumours < 2 cm [116].
The use of MR urography with gadolinium-based contrast media should be limited in patients with
severe renal impairment (< 30 mL/min creatinine clearance), due to the risk of NSF. Computed
tomography urography is generally preferred to MR urography for diagnosing and staging UTUC.

5.2.4.Distant metastases at sites other than lymph nodes

Prior to any curative treatment, it is essential to evaluate the presence of
distant metastases. Computed tomography and MRI are the diagnostic techniques of choice to detect
lung [117]
and liver metastases [118],
respectively. Bone and brain metastases are rare at the time of presentation of invasive BC. A bone
scan and additional brain imaging are therefore not routinely indicated unless the patient has
specific symptoms or signs to suggest bone or brain metastases [119,120].
Magnetic resonance imaging is more sensitive and specific for diagnosing bone metastases than bone
scintigraphy [121,122]
(LE: 2b).

5.2.5.Future developments

Evidence is accruing in the literature suggesting that 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT
might have potential clinical use for staging metastatic BC [123,124],
but there is no consensus as yet. The results of further trials are awaited before a recommendation
can be made. Recently, the first study was published showing the superior feasibility of DWI over
T2-weighted and DCE MRI for assessing the therapeutic response to induction chemotherapy against
MIBC [125].
The high specificity of DWI indicates that it is useful for accurate prediction of a complete
histopathological response, allowing better patient selection for bladder-sparing protocols. Results
from prospective studies are awaited.

5.2.6.Summary of evidence and guidelines for staging in muscle-invasive bladder cancer

Summary of evidence

LE

Imaging as part of staging in
muscle-invasive bladder cancer (MIBC) provides information about prognosis and assists in
selection of the most appropriate treatment.

2b

There are currently
insufficient data on the use of diffusion-weighted imaging (DWI) and 18F-fluorodeoxyglucose-positron emission
tomography/computed tomography (FDG-PET/CT) in MIBC to allow for a recommendation to be
made.

The diagnosis of upper tract
urothelial carcinoma depends on CT urography and ureteroscopy.

2

Recommendations

Strength
rating

In patients with
confirmed MIBC, use computed tomography (CT) of the chest, abdomen and pelvis as the optimal
form of staging.

Strong

Perform a CT
urography for upper tract evaluation and for staging.

Strong

For upper tract
evaluation, use diagnostic ureteroscopy and biopsy only in cases where additional
information will impact treatment decisions.

Strong

Use magnetic
resonance urography when CT urography is contraindicated for reasons related to contrast
administration or radiation dose.

Strong

Use CT or magnetic
resonance imaging (MRI) for staging locally advanced or metastatic disease in patients in
whom radical treatment is considered.

Strong

Use CT to diagnose
pulmonary metastases. Computed tomography and MRI are generally equivalent for diagnosing
local disease and distant metastases in the abdomen.

Strong

6.PROGNOSIS

6.1.Introduction

Both patient and tumour characteristics impact on the prognosis of patients with
MIBC. Treatment and prognosis for MIBC are mainly based on tumour and nodal stage [93].

6.2.MIBC and comorbidity

Complications related to RC may be directly related to pre-existing comorbidity as
well as the surgical procedure, bowel anastomosis, or urinary diversion. A significant body of
literature has evaluated the usefulness of age as a prognostic factor for RC, although chronological
age is less important than biological age [126-128].
Controversy remains regarding age, RC and the type of urinary diversion. Radical cystectomy is
associated with the greatest risk reduction in disease-related and non-disease-related death in
patients aged > 80 years [129].

The largest retrospective study on RC in septuagenarians and
octogenarians based on data from the National Surgical Quality Improvement Program database (n =
1,710) showed no significant difference for wound, cardiac, or pulmonary complications. However, the
risk of mortality in the octogenarians compared to the septuagenarians is higher (4.3% vs. 2.3%) [130].
Although some octogenarians successfully underwent a neobladder procedure, most patients were
treated with an ileal conduit diversion.

It is important to evaluate functioning and quality of life (QoL)
of elderly patients using a standardised geriatric assessment, as well as carrying out a standard
medical evaluation [131].

Sarcopenia has been shown to be an independent predictor for OS and CSS in a large
multicentre study with patients undergoing RC for BC [132].
Other risk factors for morbidity include prior abdominal surgery, extravesical disease, and prior RT
[133].
Female gender, an increased body mass index (BMI) and lower pre-operative albumin levels are
associated with a higher rate of parastomal hernias [134].

Low pre-operative serum albumin is also associated with impaired
wound healing, gastrointestinal complications and a decrease of recurrence-free and OS after RC [135,136].
Therefore, it could be used as a prognostic biomarker for patients undergoing RC.

6.2.1.Evaluation of comorbidity

Rochon et al. have shown that evaluation of
comorbidity provides a better indicator of life expectancy in MIBC than patient age [137].
Evaluation of comorbidity helps to identify the medical conditions likely to interfere with, or have
an impact on, treatment and the evolution and prognosis of MIBC [138].

The value of assessing overall health before recommending and
proceeding with surgery was emphasised by Zietman et al., who
have demonstrated an association between comorbidity and adverse pathological and survival outcomes
following RC [139].
Similar results were found for the impact of comorbidity on cancer-specific and other-cause
mortality in a population-based competing risk analysis of > 11,260 patients from the
Surveillance, Epidemiology, and End Results (SEER) registries. Age carried the highest risk for
other-cause mortality but not for increased cancer-specific death, while the stage of locally
advanced tumour was the strongest predictor for decreased CSS [140].
Stratifying elderly patients according to their risk-benefit profile using a multidisciplinary
approach will help to select patients most likely to benefit from radical surgery and to optimise
treatment outcomes [141].
Unfortunately, most series evaluating RC do not include indices of comorbidity in the patient
evaluation.

A range of comorbidity scales has been developed [142],
six of which have been validated [143-148]
(LE: 3). The Charlson Comorbidity Index (CCI) ranges from 0 to 30 according to the importance
of comorbidity described at four levels and is calculated by healthcare practitioners based on
patients’ medical records. The score has been widely studied in patients with BC and found to be an
independent prognostic factor for peri-operative mortality [149,150],
overall mortality [151],
and CSM [129,152-154].
Only the age-adjusted version of the CCI was correlated with both cancer-specific and other-cause
mortality [155].
The age-adjusted CCI (Table 6.1) is the most widely used comorbidity index in cancer for estimating
long-term survival and is easily calculated [156].

Table 6.1: Calculation of the Charlson Comorbidity Index

Number of
points

Conditions

1

50-60 years

Myocardial infarction

Heart failure

Peripheral vascular
insufficiency

Cerebrovascular disease

Dementia

Chronic lung disease

Connective tissue disease

Ulcer disease

Mild liver disease

Diabetes

2

61-70 years

Hemiplegia

Moderate to severe kidney
disease

Diabetes with organ damage

Tumours of all origins

3

71-80 years

Moderate to severe liver
disease

4

81-90 years

5

> 90 years

6

Metastatic solid tumours

AIDS

Interpretation

1.Calculate Charlson
Comorbidity Score or Index = i

Add comorbidity
score to age score

Total denoted as ‘i’
in the Charlson Probability calculation (see below). i = sum of comorbidity score to age score

2.Calculate Charlson
Probability (10-year mortality = Y)

Calculate Y =
10(i x 0.9)

Calculate _Z = 0.983Y
(where _Z is the 10-year survival)

Health assessment of oncology patients must be supplemented by measuring their
activity level. Extermann et al. have shown that there is
no correlation between morbidity and competitive activity level [157].
The Eastern Cooperative Oncology Group (ECOG) performance status (PS) scores and Karnofsky index
have been validated to measure patient activity [158]
(LE: 3). Performance score is correlated with patient OS after RC [153]
and palliative chemotherapy [159-161].

According to a consensus conference of the National Institutes of Health, the aim
of the Standardized Geriatric Assessment (SGA) is to discover, describe and explain the many
problems of elderly people, to catalogue their resources and strengths, to assess individual service
needs, and to develop a coordinated plan of care. The SGA can be carried out by means of several
protocols. These protocols differ in the completeness of diagnostic research. The most complete
protocol is the Comprehensive Geriatric Assessment (CGA) [162]
which is tailored to the care of cancer patients [163].
In BC, the CGA has been used to adapt gemcitabine chemotherapy in previously untreated elderly
patients with advanced BC [164].

6.2.3.Summary of evidence and guidelines for comorbidity scales

Summary of evidence

LE

Chronological age is of
limited relevance.

3

A comorbidity score developed
in particular for the assessment of patients diagnosed with bladder cancer would be
helpful.

3

Recommendations

Strength
rating

Base the decision on
bladder-sparing treatment or radical cystectomy in elderly/geriatric patients with invasive
bladder cancer on tumour stage and comorbidity.

Strong

Assess comorbidity by
a validated score, such as the Charlson Comorbidity Index. The American Society of
Anesthesiologists score should not be used in this setting (see Section 7.4.4.1).

Strong

6.3.Prognostic markers

6.3.1.Clinical and histopathological parameters

The most important histopathological prognostic variables after RC and LN
dissection are tumour stage and LN status [165].
In addition, other histopathological parameters of the RC specimen have been associated with
prognosis.

The value of lymphovascular invasion was reported in a SR and
meta-analysis including 78,000 patients from 65 studies treated with RC for BC [166].
Lymphovascular invasion was present in 35% of the patients and correlated with a 1.5-fold higher
risk of recurrence and cancer mortality, independent of pathological stage and peri-operative
chemotherapy. This correlation was even stronger in those patients with node-negative disease [167].

In a SR and meta-analysis including 23 studies and over 20,000
patients, the presence of concomitant CIS in the RC specimen was associated with a higher odds ratio
(OR) of ureteral involvement (pooled OR: 4.51, 2.59-7.84). Concomitant CIS was not independently
associated with OS, recurrence-free survival (RFS) and DSS survival in all patients, but in patients
with organ-confined disease concomitant CIS was associated with worse RFS (pooled HR: 1.57,
1.12-2.21) and CSM (pooled HR: 1.51, 1.001-2.280) [168].

Tumour location has been associated with prognosis. Tumours located at the bladder
neck or trigone of the bladder appear to have an increased likelihood of nodal metastasis (OR: 1.83
95% CI: 1.11-2.99) and have been associated with decreased survival [92,165].

Prostatic urethral involvement at the time of RC was also found
to be associated with worse survival outcomes. In a series of 995 patients, prostatic involvement
was recorded in 31% of patients. The five-year CSS in patients with CIS of the prostatic urethra was
40%, whilst the prognosis of patients with UC invading the prostatic stroma was worse with a
five-year CSS of only 12% [169].

In patients with LN-positive disease a SR and meta-analysis reported that LN
density, defined as the ratio of positive LNs to the number of LNs removed, was independently
associated with OS (HR: 1.45; 95%, CI: 1.11-1.90) [170].
It has been suggested that LN density outperforms the AJCC-TNM staging system for LN-positive
disease in terms of prognostic value [171].
However, in spite of these studies supporting the use of LN density, LN density relies on the number
of LNs removed which, in turn, is subject to surgical and pathological factors. This makes the
concept of LN density difficult to apply uniformly.

Biomarkers such as C-reactive protein, lymphocyte-monocyte ratio (LMR), or
platelet-lymphocyte ratio (PLR) have been investigated. Recently neutrophil-to-lymphocyte ratio
(NLR) has emerged as a prognostic factor in UUT tumours [1]
and other non-urological malignancies. In a pooled analysis of 21 studies analysing the prognostic
role of NLR in BC, the authors correlated elevated pre-treatment NLR with OS, RFS and DFS in both
localised and metastatic disease [172].
In contrast, a secondary analysis of the SWOG 8710 trial, a randomised phase III trial that assessed
cystectomy ± neoadjuvant chemotherapy (NAC) in patients with MIBC, suggests that NLR is neither a
prognostic nor predictive biomarker for OS in MIBC, nor could an OS benefit from NAC be demonstrated
[173].

Several studies have already demonstrated that systemic inflammation correlates
with worse prognosis in several malignancies.

6.3.2.Molecular markers

6.3.2.1.Molecular groups based on the Cancer
Genome Atlas (TCGA) cohort

It has been attempted to classify UC from a molecular point of view. Four major
systems exist:

basal BC with the basal and claudin low-type group;

luminal BC with luminal and p53-like subtype.

The basal group, which can have sarcomatoid aspects and shows an over-expression of
epidermal growth factor receptor 3 (EGFR3), is chemosensitive, the luminal type displays an
over-expression of fibroblast growth factor receptor 3 (FGFR3), epidermal growth factor receptor
(ERBB2↑ and ERBB3), and is chemotherapy resistant [54,55,174].

These molecular classifications have been updated in the last four years, as have
the TCGA and the Lund classifications [175,176].
According to their molecular appearance urothelial carcinomas react differently to different
therapies [175,177].
Warrick et al. found that intratumoural molecular heterogeneity
and great somatic mutation burden could also be related to therapeutic response [178].
However, molecular classification of MIBC is still evolving and treatment according to the molecular
subtype is not a standard yet. In the coming years, new insights into BC carcinogenesis may change
our management of the disease.

6.3.2.2.Other
molecular markers

The performance of current commercially available pathological prognostic markers points to the relevance of including molecular prognostic markers in clinical practice [179], but so far very few studies have addressed this topic. At present, insufficient evidence exists to recommend the standard use of prognostic marker p53 in high-risk muscle-invasive disease, as it will not yield sufficient data to base treatment on in an individual patient [180].

Beyond the recently developed molecular classification for MIBC, as yet, no other
molecular markers can be considered for use in standard clinical practice although several markers
(mainly predictive markers assessing response to NAC) are now being evaluated, such as tumour
mutation burden (TMB), DNA damage response (DDR) gene defects and mismatch repair defects or
microsatellite instability [178].
Further research is needed to establish their role as predictive and prognostic markers in patient
selection.

7.DISEASE MANAGEMENT

7.1.Treatment failure of non-muscle invasive bladder
cancer

7.1.1.High-risk non-muscle-invasive urothelial carcinoma

In 2015 the European Organisation for Research and Treatment of Cancer (EORTC)
group presented new nomograms based on two large phase III trials with a median follow-up of 7.4
years. These showed that with one to three years of maintenance Bacillus Calmette-Guérin (BCG), the
risk for progression at five years was 19.3% for T1G3 tumours [181].
Meta-analyses have demonstrated that BCG-therapy prevents the risk of tumour recurrence [182]
and the risk of tumour progression [183,184],
but so far, no significant overall- or disease-specific survival advantages have been shown, as
compared to no intravesical therapy [183-185].
The EAU NMIBC Guidelines present data supporting cystectomy in selected patients with NMIBC.

Large cystectomy series show a risk of an understaging error in
TaT1 tumours of 35-62%. This may be caused by the presence of persisting or recurrent tumours due to
omission of a second TURB or re-TURB, and the absence of neoadjuvant therapy [186-188].
Second TURB identifies upstaging to > T2 tumours in 10-20% of patients [189,190].
Residual T1 disease in second TURB is associated with a higher recurrence and progression rate, as
well as with a higher CSM [191].

Progression to MIBC has been shown to significantly decrease CSS.
In a review of nineteen trials including 3,088 patients, CSS after progression from NMIBC to MIBC
was 35%, which is significantly worse compared to patients with MIBC without a history of NMIBC.
Although all studies reflect these findings, a large retrospective Canadian study showed that even
progressive patients had a slightly better outcome [192].
High-grade T1 disease remains a dangerous disease, which underlines the need to recommend early
radical treatment, such as RC, in case of intravesical therapy failure [2,193].

According to the EAU NMIBC Guidelines, it is reasonable to propose immediate RC to
patients with non-muscle-invasive tumours who are at highest risk of progression [194-196].
Risk factors are any of the following:

T1 tumours;

G3 (high grade) tumours;

CIS;

multiple, recurrent and large (> 3 cm) TaG1G2/low-grade tumours (all features must be
present).

Although the percentage of patients with primary TaT1 tumours and the indication
for cystectomy in TaT1 tumours is not specified in large cystectomy series, the ten-year RFS rate is
80% and similar to that of TURB and BCG maintenance therapy [2,187,197,198]
(LE: 3).

Radical cystectomy is also strongly recommended in patients with a muscle-invasive
tumour detected during follow up, in BCG-refractory tumours, BCG relapse and BCG unresponsive
tumours, which are defined in the NMIBC guideline as [2]:

BCG-refractory tumour:

if T1 high-grade/G3, non-muscle-invasive papillary tumour is present at three months;

if Ta high-grade/G3 or CIS (without concomitant papillary tumour) is present at both three and
six months (after a second induction course or the first maintenance course of BCG);

Bacillus Calmette-Guérin-refractory or T1 BCG relapse within six months or CIS within twelve
months of last BCG exposure.

Patients with disease recurrence within two years of initial TURB plus BCG therapy
have a better outcome than patients who already have muscle-invasive disease, indicating that
cystectomy should be performed at first recurrence, even in non-muscle-invasive disease [200]
(LE: 3).

There are now several bladder-preservation strategies available; immunotherapy,
chemotherapy, device-assisted therapy, and combination therapy [201].
However, experience is limited and treatments other than RC must be considered oncologically
inferior at the present time [201].

Discuss immediate
radical treatment in all T1 tumours at high risk of progression (i.e. high grade,
multifocality, carcinoma in situ, and tumour size, as
outlined in the EAU Guidelines for Non-muscle-invasive Bladder Cancer).

7.2.Neoadjuvant therapy

7.2.1.Introduction

The standard treatment for patients with urothelial MIBC and MIBC with variant
histologies is RC. However, RC only provides five-year survival in about 50% of patients [188,202-205].
To improve these results, cisplatin-based NAC has been used since the 1980s [188,202-207].

7.2.2.Role of cisplatin-based chemotherapy

There are theoretical advantages and disadvantages of administering chemotherapy
before planned definitive surgery to patients with resectable muscle-invasive UC of the bladder and
cN0M0 disease:

Chemotherapy is delivered at the earliest time-point, when the burden of micrometastatic disease
is expected to be low.

Potential reflection of in-vivo chemosensitivity.

Tolerability of chemotherapy and patient compliance are expected to be better pre-cystectomy.

Delayed cystectomy might compromise the outcome in patients not sensitive to chemotherapy [208,209],
although published studies on the negative effect of delayed cystectomy only include chemo-naïve
patients. There are no trials indicating that delayed surgery due to NAC has a negative impact
on survival.

Neoadjuvant chemotherapy does not seem to affect the outcome of surgical morbidity. In one
randomised trial the same distribution of grade 3-4 post-operative complications was seen in
both treatment arms [210].
In the combined Nordic trials (n = 620), NAC did not have a major adverse effect on the
percentage of performable cystectomies. The cystectomy frequency was 86% in the experimental arm
and 87% in the control arm with 71% of patients receiving all three chemotherapy cycles [211].

Clinical staging using bimanual palpation, CT or MRI may result in over- and understaging and
have a staging accuracy of only 70% [68].
Overtreatment is a possible negative consequence.

Neoadjuvant chemotherapy should only be used in patients eligible for cisplatin combination
chemotherapy; other combinations (or monotherapies) are inferior in metastatic BC and have not
been fully tested in a neoadjuvant setting [210,212-220].

7.2.2.1. Summary of available data

Several randomised phase III trials addressed the potential survival benefit of NAC
administration [210,212-217,221-225].
The main differences in trial designs were the type of chemotherapy (i.e. single-agent cisplatin or
combination chemotherapy) and the number of cycles provided. Patients had to be fit for cisplatin.
Since these studies differed considerably for patient numbers, patient characteristics (e.g.
clinical T-stages included) and the type of definitive treatment offered (cystectomy and/or RT),
pooling of results was not possible.

Three meta-analyses were undertaken to establish if NAC prolongs survival [218-220].
In a meta-analysis, published in 2005 [220]
with updated patient data from eleven randomised trials (n = 3,005), a significant survival benefit
was shown in favour of NAC.

The most recent meta-analysis included four additional randomised
trials, and used the updated results from the Nordic I, Nordic II, and BA06 30894 trials, consisting
of information for 427 new patients and updated information for 1,596 patients. The results of this
analysis confirmed the previously published data and showed an 8% absolute improvement in survival
at five years with a number needed-to-treat of 12.5 [226].

The updated analysis of a large randomised phase III trial [212]
with a median follow-up of eight years confirmed previous results and provided additional findings:

16% reduction in mortality risk;

improvement in ten-year survival from 30% to 36% with neoadjuvant CMV;

benefit with regard to distant metastases;

no benefit for locoregional control and locoregional DFS, with the addition of neoadjuvant CMV
independent of the definitive treatment.

More modern chemotherapeutic regimens such as gemcitabine/cisplatin have shown
similar pT0/pT1 rates as methotrexate, vinblastine, adriamycin plus cisplatin (MVAC) in
retrospective series and pooled data analyses, but have not been used in randomised controlled
trials (RCTs) [227-230].
Recently modified dose-dense MVAC (ddMVAC) was tested in two small single arm phase II studies
demonstrating high rates of pathologic complete remission [231,232].
Moreover, a large cross-sectional analysis showed higher rates of downstaging and pathological
complete response for ddMVAC [233].

It is unclear, if patients with non-urothelial carcinoma
histology can also benefit from NAC. A retrospective analysis demonstrated that patients with
neuroendocrine tumours had improved OS and lower rates of non-organ-confined disease when receiving
NAC. In case of micropapillary differentiation, sarcomatoid differentiation and adenocarcinoma,
lower rates of non-organ confined disease were found, but no statistically significant impact on OS.
Patients with SCC did not benefit from NAC [234].

A retrospective analysis assessed the use of NAC in MIBC based on data from the
U.S. National Cancer Database [235].
Only 19% of all patients received NAC before radical cystectomy (1,619 of 8,732 patients) and no
clear survival advantage for NAC following propensity score adjustment was found despite efforts to
include patients based on SWOG 8710 study criteria [210].
Therefore, these results have to be interpreted with caution, especially since there is no
information about the type of NAC applied, however, these findings emphasise the importance of
pragmatically designed studies that reflect real-life practice.

7.2.3.The role of imaging and biomarkers to identify responders

Data from small imaging studies aiming to identify responders in patients treated
with NAC suggest that response after two cycles of treatment is related to outcome. Although
multiparametric (mp) MRI has the advantage of better resolution of the bladder wall tissue planes as
compared to CT without radiation exposure, it is not ready yet for standard patient care. However,
bladder mpMRI may be useful to inform on tumour stage after TUR and response to NAC [236].
So far neither PET, CT, conventional MRI or DCE MRI can accurately assess treatment response [237-240].
In addition, the definition of stable disease after two cycles of NAC is still undefined. To
identify progression during NAC, imaging is being used in many centres, notwithstanding the lack of
supporting evidence.

For responders to NAC, especially in those with a complete
response (pT0 N0), treatment has a major positive impact on OS [241].
Therefore, reliable predictive markers to identify patients most likely to benefit from treatment
are needed. Molecular tumour profiling might guide the use of NAC in the future [242,243]
(see Section 7.8.12 - Biomarkers).

7.2.4.Role of neoadjuvant immunotherapy

Checkpoint inhibitors have shown significant benefit in patients with unresectable
and metastatic BC in the salvage setting and in platinum-ineligible PD-L1+ patients as first-line
treatment. A number of PD1/PD-L1 inhibitors have received regulatory approval and are currently
being tested in several ongoing phase II trials whilst phase III trials are accruing. The initial
data from two phase II trials with pembrolizumab and atezolizumab show promising results [244].

7.2.5.Summary of evidence and guidelines for neoadjuvant therapy

Neoadjuvant treatment of
responders and especially patients who show complete response (pT0 N0) has a major impact on
OS.

2

Currently immunotherapy with
checkpoint inhibitors is tested in phase II and III trials. Initial results are
promising.

There are still no tools
available to select patients who have a higher probability of benefitting from NAC. In the
future, genetic markers, in a personalised medicine setting, might facilitate the selection
of patients for NAC and differentiate responders from non-responders.

Neoadjuvant chemotherapy has
its limitations regarding patient selection, current development of surgical techniques, and
current chemotherapy combinations.

7.3.1.Post-operative radiotherapy

The data on adjuvant RT after RC are very limited and old. However, advances in
targeting and reducing the damage to surrounding tissue, may yield better results in the future [245].
A RCT, comparing pre-operative vs. post-operative RT and RC (n = 100), showed comparable OS, DFS and
complication rates [246].
Approximately half of these patients had urothelial cancer (UC), while the other half had SCC. In
locally advanced BC (T3-T4, N0/N1, M0), the local recurrence rate seems to decrease with
post-operative RT [247].

7.3.2.Pre-operative radiotherapy

7.3.2.1.Retrospective studies

Older data and retrospective studies alone cannot provide an evidence base for
modern guideline recommendations due to major study limitations, which include concomitant
chemotherapy and differences between surgery and RT. This conclusion was supported by a 2003 SR [248].
A retrospective study from 2015 [249]
showed decreased cause-specific mortality and overall mortality for pre-operative RT in clinical T2b
and T3 patients only. Another retrospective study with pre-operative RT in clinical T1-3 tumours
showed that downstaging to T0 tumours occurs in > 50% of the irradiated patients, as compared to
< 10% of patients who did not receive pre-operative RT [250].
Additionally, downstaging resulted in a longer progression-free survival (PFS).

7.3.2.2.Randomised studies

To date, six randomised studies have been published, investigating pre-operative
RT, although all are from several decades ago. In the largest trial, pre-operative RT at a dose of
45 Gy was used in patients with muscle-invasive tumours resulting in a significant increase in
pathological complete response (9% to 34%) in favour of pre-operative RT, which was also a
prognostic factor for survival [251].
The OS data were difficult to interpret since chemotherapy was used in a subset of patients only and
more than 50% of patients (241/475) did not receive the planned treatment and were excluded from the
final analyses. Two smaller studies using a dose of 20 Gy showed only a small survival advantage in
> T3 tumours [252,253].
Two other small trials confirmed downstaging after pre-operative RT [254,255].

A meta-analysis of the five randomised trials showed a difference
in five-year survival (OR: 0.71; 95% CI: 0.48-1.06) in favour of pre-operative RT [256].
However, the meta-analysis was potentially biased by data from the largest trial in which patients
were not given the planned treatment. When the largest trial was excluded from the analysis, the OR
became 0.94 (95% CI: 0.57-1.55), which was not significant.

7.3.3.Summary of evidence and guidelines for pre- and post-operative radiotherapy

Pre-operative RT for operable
MIBC, using a dose of 45-50 Gy in fractions of 1.8-2 Gy, results in downstaging after
four-six weeks.

2

Limited high-quality evidence
supports the use of pre-operative RT to decrease local recurrence of MIBC after radical
cystectomy.

3

Recommendations

Strength
rating

Do not offer
pre-operative radiotherapy (RT) for operable MIBC since it will only result in downstaging,
but will not improve survival.

Strong

Do not offer
pre-operative RT when subsequent radical cystectomy with urinary diversion is planned.

Strong

7.4.Radical surgery and urinary diversion

7.4.1.Removal of the tumour-bearing bladder

7.4.1.1.Introduction

Radical cystectomy is the standard treatment for localised MIBC in most Western
countries [188,257].
Recent interest in patients’ QoL has promoted the trend toward bladder-preserving treatment
modalities, such as radio- and/or chemotherapy (see Section 7.6). Performance status and life
expectancy influence the choice of primary management, as well as the type of urinary diversion,
with cystectomy being reserved for patients with a longer life expectancy without concomitant
disease and a better PS. The value of assessing overall health before proceeding with surgery was
emphasised in a multivariate analysis [129].
The analysis found an association between comorbidity and adverse pathological- and survival
outcomes following RC [129].
Performance status and comorbidity have a different impact on treatment outcomes and must be
evaluated independently [157].

7.4.1.2.Radical cystectomy: timing

An analysis of the Netherlands Cancer Registry showed that a delay of RC > 3
months was not associated with a worse clinical outcome [258].
Previously, Ayres et al. also found that in the United Kingdom
cystectomy within 90 days of diagnosis had no effect on OS for MIBC (n = 955). However, analysis of
T2 tumours showed a statistically significant survival benefit if patients had surgery within 90
days of diagnosis (n = 543; HR: 1.40; 95% CI: 1.10-1.79) [259].
A population-based study from the U.S. SEER database analysed patients who underwent a cystectomy
between 2001 and 2011 and concluded that a delay of more than twelve weeks has a negative impact on
outcome and should be avoided [260].
Moreover, the SEER analysis did not show any significant utilisation and timing differences between
men and women.

7.4.2.Radical cystectomy: indications

Traditionally, RC was recommended for patients with MIBC T2-T4a, N0-Nx, M0 [257].
Other indications include high risk and recurrent non-muscle-invasive tumours, BCG-refractory,
BCG-relapsing and BCG-unresponsive, T1G3 tumours (see Section 7.1), as well as extensive papillary
disease that cannot be controlled with TURB and intravesical therapy alone.

Salvage cystectomy is indicated in non-responders to conservative therapy,
recurrence after bladder-sparing treatment, and non-UC (these tumours respond poorly to chemotherapy
and RT). It is also used as a purely palliative intervention, including for fistula formation, pain
and recurrent visible haematuria (see Section 7.5.1 - Palliative cystectomy).

When there are positive LNs, in the case of N1 involvement
(metastasis in a single node in the true pelvis) orthotopic neobladder can still be considered, but
not in N2 or N3 tumours [261].

7.4.3.Radical cystectomy: technique and extent

In men, standard RC includes removal of the bladder, prostate, seminal vesicles,
distal ureters, and regional LNs. Prostate-sparing cystectomy is an option in a subset of carefully
selected patients with BC without involvement of the prostatic urethra and without prostate cancer.
This procedure is oncologically safe with good functional results as long as it is performed in an
experienced centre [262].
In women, standard RC includes removal of the bladder, entire urethra and adjacent vagina, uterus,
distal ureters, and regional LNs [263].
Controversies in evaluating the clinical significance of lymphadenectomy are related to two main
aspects of nodal dissection: therapeutic procedure and/or staging instrument.

Two important autopsy studies for RC have been performed so far. The first study
showed that in 215 patients with MIBC and nodal dissemination, the frequency of metastasis was 92%
in regional (perivesical or pelvic), 72% in retroperitoneal, and 35% in abdominal LNs. There was
also a significant correlation between nodal metastases and concomitant distant metastases (p <
0.0001).

Approximately 47% of the patients had both nodal metastases and
distant dissemination and only 12% of the patients had nodal dissemination as the sole metastatic
manifestation [264].
The second autopsy study focused on the nodal yield when super-extended pelvic LN dissection (LND)
was performed. Substantial inter-individual differences were found with counts ranging from 10 to 53
nodes [265].
These findings demonstrate the limited utility of node count as a surrogate for extent of
dissection.

Regional LNs have been shown to consist of all pelvic LNs below the bifurcation of
the aorta [266-270].
Mapping studies have also found that skipping lesions at locations above the bifurcation of the
aorta, without more distally located LN metastases, is rare [270,271].

The optimal extent of LND has not been established to date. Standard
lymphadenectomy in BC patients involves removal of nodal tissue cranially up to the common iliac
bifurcation, with the ureter being the medial border, and including the internal iliac, presacral,
obturator fossa and external iliac nodes [272].
Extended lymphadenectomy includes all LNs in the region of the aortic bifurcation, and presacral and
common iliac vessels medial to the crossing ureters. The lateral borders are the genitofemoral
nerves, caudally the circumflex iliac vein, the lacunar ligament and the LN of Cloquet, as well as
the area described for standard lymphadenectomy [272-276].
A super-extended lymphadenectomy extends cranially to the level of the inferior mesenteric artery
[277,278].

In order to assess how and if cancer outcome is influenced by the extent of
lymphadenectomy in patients with clinical N0M0 MIBC, a SR of the literature was undertaken [279].
Out of 1,692 abstracts retrieved and assessed, nineteen studies fulfilled the review criteria [272-276,278,280-292].
All five studies comparing LND vs. no LND reported a better oncological outcome for the LND group.
Seven out of twelve studies comparing (super) extended with limited or standard LND reported a
beneficial outcome for (super) extended LND in at least a subset of patients which is in concordance
with the findings of several other meta-analyses [293,294].
No difference in outcome was reported between extended and super-extended LND in the two
high-volume-centre studies identified [278,290].
A prospective randomised phase III study including 401 patients with a median follow-up of 43 months
recently reported [295].
Extended LND failed to show a significant advantage over limited LND in RFS, CSS, and OS. Results
from another large RCT on the therapeutic impact of the extent of lymphadenectomy are expected
shortly.

It has been suggested that PFS as well as OS might be correlated with the number of
LNs removed during surgery. Although there are no data from RCTs on the minimum number of LNs that
should be removed, survival rates increase with the number of dissected LNs [296].
Removal of at least ten LNs has been postulated as sufficient for evaluation of LN status, as well
as being beneficial for OS in retrospective studies [297-299].
Submitting separate nodal packets instead of en bloc has shown
significant increased total LN yield, but did not result in an increased number of positive LNs,
making LN density an inaccurate prognosticator [300].
In conclusion, extended LND might have a therapeutic benefit compared to less extensive LND, but due
to study bias no firm conclusions can be drawn [135,279].

Different approaches have been described to improve voiding and sexual function in
patients undergoing RC for BC. No consensus exists regarding which approach preserves function best.
Concern remains regarding the impact of “sparing-techniques” on oncological outcomes.

To determine the effect of sexual function-preserving cystectomy
(SPC) on functional and oncological outcomes the EAU MIBC Panel undertook a SR [301].

Four main types of sexual-preserving techniques have been described:

1.Prostate sparing cystectomy:
part of or the whole prostate is preserved including seminal vesicles, vas deferens and
neurovascular bundles.

2.Capsule sparing cystectomy:
the capsule or peripheral part of the prostate is preserved with adenoma (including prostatic
urethra) removed by TURP or en bloc with the bladder. Seminal
vesicles, vas deferens and neurovascular bundles are also preserved.

4.Nerve-sparing cystectomy:
the neurovascular bundles are the only tissue left in place.

Twelve studies recruiting a total of 1,098 patients were identified, including nine
comparative studies [262,302-311]
and three single-arm case series [312-314].
In the majority of cases, the open surgical approach was used and the urinary diversion of choice
was an orthotopic neobladder. Median follow-up was longer than three years in nine studies, with
three studies presenting results with a median follow-up longer than five years.

The majority of the studies included patients who were potent pre-operatively with
organ-confined disease without tumour in the bladder neck and/or prostatic urethra. Prostate cancer
was ruled out in all of the SPC techniques, except in nerve-sparing cystectomy.

Oncological outcomes did not differ between groups in any of the
comparative studies that measured local recurrence, metastatic recurrence, DSS and OS, at a median
follow-up of three to five years. Local recurrence after SPC was commonly defined as any UC
recurrence below the iliac bifurcation within the pelvic soft tissue and ranged from 1.2-61.1% vs.
16-55% in the control group. Metastatic recurrence ranged from 0-33.3%.

For techniques preserving prostatic tissue (prostate- or
capsule-sparing), rates of incidental prostate cancer in the intervention group ranged from 0-15%.
In no case was incidental prostate cancer with ISUP grade > 4 reported.

Post-operative potency was significantly better in patients who
underwent any type of sexual-preserving technique compared to conventional RC (p < 0.05), ranging
from 80-90%, 50-100% and 29-78% for prostate-, capsule- or nerve-sparing techniques, respectively.
Data did not show superiority of any sexual-preserving technique.

Urinary continence, defined as the use of no pads in the majority
of studies, ranged from 88-100% (day-time continence) and from 31-96% (night-time continence) in the
prostate-sparing cystectomy patients. No major impact was shown with regard to continence rates for
any of the three approaches.

The evidence base suggests that these procedures may yield better sexual outcomes
than standard cystectomy without compromising oncological outcomes. However, the overall quality of
the evidence was moderate, and hence if a sexual-preserving technique is offered, patients must be
carefully selected, counselled and closely monitored.

7.4.3.1.1.Summary of evidence and recommendations for sexual-preserving
techniques in men

Summary of evidence

LE

The majority of patients
motivated to preserve their sexual function will benefit from sexual-preserving
techniques.

2a

None of the sexual-preserving
techniques (prostate/capsule/seminal/nerve-sparing) have shown to be superior, and no
particular technique can be recommended.

3

Recommendations

Strength
rating

Do not offer
sexual-preserving cystectomy to men as standard therapy for muscle-invasive bladder
cancer.

Strong

Offer
sexual-preserving techniques to men motivated to preserve their sexual function since the
majority will benefit.

Strong

Select patients based
on:

organ-confined disease;

absence of any kind of tumour at the level of the
prostate, prostatic urethra or bladder neck.

Sexual and voiding dysfunction in female patients is prevalent after RC and
orthotopic neobladder. Patients’ QoL has promoted the trend toward pelvic organ-preserving
techniques. Better imaging modalities, increased knowledge of the function of the pelvic structures
and improved surgical techniques have enabled less destructive methods for treating high-risk BC.
These techniques involve preserving the neurovascular bundle, vagina, uterus or variations of any of
the stated techniques.

A SR was conducted to evaluate the advantages and disadvantages
of sexual-function preserving RC and orthotopic neobladder in female patients [315].
After screening 11,941 abstracts, fifteen studies recruiting a total of 874 patients were eligible
for inclusion. Three papers had a matched pair study design, and the remainder of the included
studies were retrospective surgical series with small case numbers and a high risk of selection bias
favouring less advanced cancers.

Sexual outcomes were reported in seven studies with 167/194
patients (86%) having resumed sexual activity within six months post-operatively, with median
patients’ sexual satisfaction scores of 88.5%, ranging from 80-100%.

Survival outcomes were reported in seven studies with 197
patients, with a mean follow-up of between 12 and 132 months. At three and five years, CSS was
70-100% and OS was 65-100%, respectively. Positive surgical margins were reported in six studies,
ranging from 0-13.7%. Local and metastatic recurrence rates were reported as ranging between 0-13%
and 0-16.7%, respectively. Mean time to local recurrence was seven months.

Although this SR provides the best evidence currently available,
including all reported cases, the data remains immature. Most studies were retrospective and
non-comparative with small numbers of patients included, meaning that any estimates are uncertain
and likely to be biased. Heterogeneity in outcome definition, measurement and reporting hampers the
usefulness of the current evidence base. The overall risk of bias was high across all studies.
However, for well-selected patients, sparing female reproductive organs during RC appears to be
oncologically safe and provides improved functional outcomes.

7.4.3.2.1.Summary of evidence and recommendations for sexual-preserving
techniques in women

Do not offer pelvic
organ-preserving radical cystectomy to women as standard therapy for muscle-invasive bladder
cancer.

Strong

Offer
sexual-preserving techniques to women motivated to preserve their sexual function since the
majority will benefit.

Weak

Select patients based
on:

organ-confined disease;

absence of tumour in bladder neck or urethra.

Strong

7.4.3.3.Laparoscopic/robotic-assisted laparoscopic
cystectomy

Due to data limitations, until recently, laparoscopic radical cystectomy (LRC) and
robot-assisted radical cystectomy (RARC) were considered as investigational procedures for which no
advantages could be shown as compared to open surgery. Most of the available studies suffered from
patient selection bias (age, stage). However, since there is now a continuous flow of reports on
RARC, this section of the text and the recommendations contained therein will be subject to
significant updates in the coming years. A number of new publications have recently become available
on RARC; a SR [316],
a consensus panel report [317],
a RCT from the Memorial Sloan Kettering Cancer Center (MSKCC) group [318],
a SR on oncologic and functional outcomes after RARC [319]
and a retrospective review on recurrence patterns after open radical cystectomy (ORC) and RARC [320].

For the methodology of the SR we refer to the manuscript by
Novara et al. [316].
In short, out of 1,071 abstracts assessed, 105 studies were selected as meeting the inclusion
criteria. Of the 105 papers 102 had a level of evidence of 4 (expert opinion), and only three
publications had a level of evidence of 2b.

For RARC with urinary diversion, the mean operative time was six
to seven hours. Although the intracorporeal technique is more demanding, operating times are
comparable, most likely reflecting more experience with the procedure. The duration of the operation
decreased over time, but remained longer than for ORC. The average operative time for ORC is listed
as 297 minutes in the three higher quality RCTs, which still seems relatively long.

In the comparative studies, mean length of hospital stay for RARC
decreases with time and experience, and is 1 to 1.5 days shorter when compared to ORC. In the RCT’s,
however, operative time and length of hospital stay showed no significant difference for either
procedure. Blood loss and transfusion rate favour RARC. Intra-operative, 30-day complication rate
and mortality were similar for RARC and ORC, but 90-day complication rates of any-grade and 90-day
grade 3 complication rates favoured RARC. Overall complication rates were reported as > 50% which
illustrates that cystectomy and diversion remains major surgery. Complication rates did not change
with time or experience.

A major limitation of this review is the low level of evidence of
the included studies. Of the three RCT’s, only one was adequately powered and there was no
correction for baseline characteristics (selection bias). In some of the larger series in the review
59-67% of tumours are < pT2 tumours. In the largest RCT 91.5% were clinically < T2 and 71.7%
pathologically < T2 [318]
compared to a large series of ORC (n = 1,054) 47% of included patients had a < pT2 tumour [188].

The Pasadena Consensus Panel (a group of experts on RC, lymphadenectomy and urinary
reconstruction) reached similar conclusions as the Novara review based on the same methodology and
literature [317].
They presented similar outcomes comparing RARC and ORC for operative endpoints, pathological and
intermediate oncological endpoints (positive surgical margins and LN yield), functional endpoints
and complication outcomes. Additionally, RARC was associated with increased costs, although there
are ergonomic advantages for the surgeon, as compared to LRC. For both techniques, surgeons’
experience and institutional volume strongly predicted outcome. According to the literature,
proficiency is reached after 20-250 cases. However, the Pasadena Consensus Panel performed
statistical modelling and came to the conclusion that 30 cases should be enough to achieve
proficiency in RARC, but they also concluded that challenging cases (high BMI, post chemotherapy or
RT, pelvic surgery, T4 or bulky tumours, or positive nodes) should be performed by experienced
robotic surgeons only. Experience is defined as a high volume centre, > 30 RARCs/year and
experience in ORC. Safety after radiotherapy was confirmed by a small (n = 46) retrospective study [321].
In experienced hands the percentage of 90-day (major) complications after robotic cystectomy was
independent of previous RT.

In the only sufficiently powered RCT, comparing ORC (n = 58) vs. RARC (n = 60) and
open diversion, the primary endpoint was an advantage in 90-day grade 2-5 complications for RARC [318].
Since the complication rates were similar (62% for RARC vs. 66% for ORC), the trial was closed after
a planned interim analysis. Robotic-assisted radical cystectomy resulted in less blood loss but had
a longer operative time and higher costs. Length of hospital stay, pathology, and QoL were similar.
Limitations of this study are lack of long-term outcomes and limited experience in RARC as compared
to ORC in this group of patients. Similar health-related quality of life (HRQoL) was also reported
in an initial report of a prospective RCT comparing ORC and RARC [322].
Similar functional and oncological outcomes with five years follow-up were reported by Yuh et al. [319].
Nguyen et al. reported that RARC was not an independent
predictor of recurrence after surgery in a retrospective review of 383 consecutive patients [320].
Most reviewed series used extracorporeal reconstruction which leaves room for improvement.

Although an intracorporeal neobladder is a very complex robotic
procedure [323],
the choice for neobladder or cutaneous diversion must not depend on the surgical approach.

For LRC, a recent review came to similar conclusions as described for RARC [323].
The review included sixteen eligible studies on LRC. As compared to ORC, LRC had a significantly
longer operative time, fewer overall complications, blood transfusions and analgesic use, less blood
loss and a shorter length of hospital stay. However, the review was limited by the inherent
limitations of the included studies. Although this review also showed better oncological outcomes,
these appeared comparable to ORC series in the largest LRC multicentre study to date [323].

The CORAL study was a small single centre RCT comparing open (n = 20) vs. robotic
(n = 20) vs. laparoscopic (n = 19) cystectomy [324].
The 30-day complication rate was significantly higher in the open arm (70%) compared to the
laparoscopic arm (26%). There was no difference between the 90-day Clavien-graded complication rates
in the three study arms. Limitations of this study include the small and below target sample size,
three different, although experienced, surgeons, and cross over between arms.

7.4.3.3.1.Summary of evidence and guidelines for
laparoscopic/robotic-assisted laparoscopic cystectomy

Summary of evidence

LE

Robot-assisted radical
cystectomy (RARC) has longer operative time (1-1.5 hours) and major costs, but shorter
length of hospital stay (1-1.5 days) and less blood loss compared to open radical cystectomy
(ORC).

1

Robot-assisted radical
cystectomy series suffer from a significant stage selection bias as compared to ORC.

1

Grade 3, 90-day complication
rate is lower with RARC.

2

Most endpoints, if reported,
including intermediate-term oncological endpoint and quality of life, are not different
between RARC and ORC.

2

Surgeons experience and
institutional volume are considered the key factor for outcome of both RARC and ORC, not the
technique.

2

Recommendations on how to
define challenging patients and an experienced RARC surgeon are still under discussion.

3

The use of neobladder after
RARC still seems under-utilised, and functional results of intracorporeally constructed
neobladders should be studied.

4

Recommendations

Strength
rating

Inform the patient of
the advantages and disadvantages of open radical cystectomy (ORC) and robot-assisted radical
cystectomy (RARC) to allow selection of the proper procedure.

Strong

Select experienced
centres, not specific techniques, both for RARC and ORC.

Strong

7.4.4.Urinary diversion after radical cystectomy

From an anatomical standpoint, three alternatives are currently used after
cystectomy:

abdominal diversion, such as an uretero-cutaneostomy, ileal or colonic conduit, and various
forms of a continent pouch;

urethral diversion, which includes various forms of gastrointestinal pouches attached to the
urethra as a continent, orthotopic urinary diversion (neobladder, orthotopic bladder
substitution);

rectosigmoid diversions, such as uretero-(ileo-)rectostomy.

Different types of segments of the intestinal tract have been used to reconstruct
the urinary tract, including the stomach, ileum, colon and appendix [325].
Several studies have compared certain aspects of HRQoL, such as sexual function, urinary continence
and body image, in patient cohorts with different types of urinary diversion. However, further
research is needed on pre-operative tumour stage and functional situation, socio-economic status,
and time interval to primary surgery.

7.4.4.1.Patient selection and preparations for surgery

The ASA score has been validated to assess the risk of post-operative complications
prior to surgery. In the BC setting, ASA scores > 3
are associated with major complications [135,326],
particularly those related to the type of urinary diversion (Table 7.4) [327].
However, the ASA score is not a comorbidity scale and should not be used as such.

No organic pathology, or
patients in whom the pathological process is localised and does not cause any systemic
disturbance or abnormality.

2

A moderate but definite
systemic disturbance caused either by the condition that is to be treated or surgical
intervention, or which is caused by other existing pathological processes.

3

Severe systemic disturbance
from any cause or causes. It is not possible to state an absolute measure of severity, as
this is a matter of clinical judgment.

4

Extreme systemic disorders
that have already become an imminent threat to life, regardless of the type of treatment.
Because of their duration or nature, there has already been damage to the organism that is
irreversible.

5

Moribund patients not expected
to survive 24 hours, with or without surgery.

In consultation with the patient, both an orthotopic neobladder and ileal conduit
should be considered in case where reconstructive surgery exposes the patient to excessive risk (as
determined by comorbidity and age).

Diagnosis of urethral tumour before cystectomy or positive
urethral frozen section leads to urethrectomy and therefore excludes neobladder reconstruction. If
indicated, in males, urethral frozen section has to be performed on the cystoprostatectomy specimen
just under the verumontanum and on the inferior limits of the bladder neck for females.

When there are positive LNs, orthotopic neobladder can
nevertheless be considered in the case of N1 involvement (metastasis in a single node in the true
pelvis) but not for N2 or N3 tumours [261].

Oncological results after orthotopic neobladder substitution or
conduit diversion are similar in terms of local or distant metastasis recurrence, but secondary
urethral tumours seem less common in patients with neobladder compared to those with conduits or
continent cutaneous diversions [329].

For cystectomy, general preparations are necessary as for any other major pelvic
and abdominal surgery. If the urinary diversion is constructed from gastrointestinal segments, the
length or size of the respective segments and their pathophysiology when storing urine must be
considered [330].
Despite the necessary interruption and re-anastomosis of bowel, a formal bowel preparation may not
be necessary [331].
Bowel recovery time can be reduced by the use of early mobilisation and early oralisation,
gastrointestinal stimulation with metoclopramide and chewing gum [332].
Patients treated according to the “fast tract”/ERAS (Early Recovery After Surgery) protocol have
shown to score better on the emotional and physical functioning scores and suffer less from wound
healing disorders, fever and thrombosis [333].

Patients undergoing continent urinary diversion must be motivated to learn about
their diversion and to be manually skilful in manipulating their diversion. Contraindications to
more complex forms of urinary diversion include:

debilitating neurological and psychiatric illnesses;

limited life expectancy;

impaired liver or renal function;

transitional cell carcinoma of the urethral margin or other surgical margins.

7.4.4.2.Different types of urinary diversion

Radical cystectomy and urinary diversion are the two steps of one operation.
However, the literature uniformly reports complications of RC, while ignoring the fact that most
complications are diversion related [337].
Age alone is not a criterion for offering continent diversion [336,338].
Comorbidity, cardiac and pulmonary function, and cognitive function, are all important factors that
should be considered, along with the patient’s social support and preference.

Age > 80 years is often considered to be the threshold after
which neobladder reconstruction is not recommended. However, there is no exact age for a strict
contraindication. In most large series from experienced centres, the rate of orthotopic bladder
substitution after cystectomy for bladder tumour is up to 80% in men and 50% in women [339-342].
Nevertheless, no RCTs comparing conduit diversion with neobladder or continent cutaneous diversion
have been performed.

A retrospective study including 1,383 patients showed that the
risk of a decline in estimated glomerular filtration rate (eGFR) did not significantly differ after
ileal conduit vs. neobladder in patients with pre-operative chronic kidney disease 2 (eGFR 60-89
mL/min/1.73 m2) or 3a (eGFR 45-59 mL/min/1.73 m2) [343].
Only age and anastomotic strictures were found to be associated with a decline in eGFR.

7.4.4.2.1.Uretero-cutaneostomy

Ureteral diversion to the abdominal wall is the simplest form of cutaneous
diversion. Operating time, complication rate, stay at intensive care and length of hospital stay are
lower in patients treated with uretero-cutaneostomy as compared to ileal conduit [344].
Therefore, in older, or otherwise compromised, patients who need a supravesical diversion,
uretero-cutaneostomy is the preferred procedure [345,346].
Quality of life, which was assessed using the Bladder Cancer Index (BCI), showed equal urinary
bother and function for patients treated with ileal conduit and uretero-cutaneostomy [344].
However, others have demonstrated that, in carefully selected elderly patients, all other forms of
wet and dry urinary diversions, including orthotopic bladder substitutions, are possible [347].

Technically, either one ureter, to which the other shorter one is attached
end-to-side, is connected to the skin (trans-uretero-cutaneostomy) or both ureters are directly
anastomosed to the skin. Due to the smaller diameter of the ureters, stoma stenosis has been
observed more often than in intestinal stomas [345].

In a retrospective multicentre study peri-operative morbidity was evaluated for
urinary diversion using bowel as compared to uretero-cutaneostomy. Patients selected for a
uretero-cutaneostomy were older and had a higher ASA score, while their mean Charlson score was
lower (4.2 vs. 5.6, p < 0.001) [348].

Despite the limited comparative data available, it must be taken
into consideration that older data and clinical experience suggest ureter stenosis at the skin level
and ascending UTI are more frequent complications in uretero-cutaneostomy compared to an ileal
conduit diversion. In a retrospective study comparing various forms of intestinal diversion, ileal
conduits had fewer late complications than continent abdominal pouches or orthotopic neobladders [349].

7.4.4.2.2.Ileal conduit

The ileal conduit is still an established option with well-known/predictable
results. However, up to 48% of patients develop early complications including UTIs, pyelonephritis,
ureteroileal leakage and stenosis [349].
The main complications in long-term follow-up studies are stomal complications in up to 24% of cases
and functional and/or morphological changes of the UUT in up to 30% [350-352].
An increase in complications was seen with longer follow-up in the Berne series of 131 patients who
were followed for a minimum of five years (median follow-up 98 months) [353];
the rate of complications increased from 45% at five years to 94% in those surviving > 15 years.
In the latter group, 50% of patients developed UUT changes and 38% developed urolithiasis.

7.4.4.2.3.Continent cutaneous urinary diversion

A low-pressure detubularised ileal reservoir can be used as a continent cutaneous
urinary diversion for self-catheterisation; gastric, ileocecal and sigma pouches have also been
described [354-356].
Different anti-reflux techniques can be used [357].
Most patients have a well-functioning reservoir with day-time and night-time continence approaching
93%
[358].
In a retrospective study of > 800 patients, stomal stenosis was seen in 23.5% of patients with an
appendix stoma and 15% of those with an efferent intussuscepted ileal nipple [358].
Stone formation in the pouch occurred in 10% of patients [357-359].
In a small series of previously irradiated female patients, incontinence and stomal stenosis was
seen in 8/44 patients (18%) [360].

7.4.4.2.4.Ureterocolonic diversion

The oldest and most common form of ureterocolonic diversion was primarily a
refluxive and later an anti-refluxive connection of ureters to the intact rectosigmoid colon
(uretero-rectosigmoidostomy) [361,362].
Most indications for this procedure have become obsolete due to a high incidence of upper UTIs and
the long-term risk of developing colon cancer [329,363].
Bowel frequency and urge incontinence are additional adverse effects of this type of urinary
diversion. However, it may be possible to circumvent these problems by interposing a segment of
ileum between the ureters and rectum or sigmoid in order to augment capacity and avoid direct
contact between the urothelium and colonic mucosa, as well as faeces and urine [364].

7.4.4.2.5.Orthotopic neobladder

An orthotopic bladder substitution to the urethra is now commonly used both in men
and women. Contemporary reports document the safety and long-term reliability of this procedure. In
several large centres, this has become the diversion of choice for most patients undergoing
cystectomy [202,257,336].
However, in elderly patients (> 80 years), it is rarely performed, even in high-volume expert
centres [365,366].
The terminal ileum is the gastrointestinal segment most often used for bladder substitution. There
is less experience with the ascending colon, including the caecum, and the sigmoid [257].
Emptying of the reservoir anastomosed to the urethra requires abdominal straining, intestinal
peristalsis, and sphincter relaxation. Early and late morbidity in up to 22% of patients is reported
[367,368].
In two studies with 1,054 and 1,300 patients [336,369],
long-term complications included diurnal (8-10%) and nocturnal (20-30%) incontinence,
ureterointestinal stenosis (3-18%), metabolic disorders, and vitamin B12 deficiency. A study
comparing cancer control and patterns of disease recurrence in patients with neobladder and ileal
conduit showed no difference in CSS between the two groups when adjusting for pathological stage [370].
Urethral recurrence in neobladder patients seems rare (1.5-7% for both male and female patients) [336,371].
These results indicate that neobladder in male and female patients does not compromise the
oncological outcome of cystectomy. It remains debatable whether neobladder is better for QoL
compared to non-continent urinary diversion [372,373].

Various forms of UUT reflux protection, including a simple
isoperistaltic tunnel, ileal intussusception, tapered ileal prolongation implanted subserosally, and
direct (sub)mucosal or subserosal ureteral implantation, have been described [357,368].
According to the long-term results, the UUT is protected sufficiently by either method.

A detailed investigation of the bladder neck prior to RC is important for women who
are scheduled for an orthotopic bladder substitute [374].
In women undergoing RC the rate of concomitant urethral malignancy has been reported to range from
12-16% [375].
Localisation of the primary tumour at the bladder neck correlated strongly with concomitant urethral
malignancy. Additionally, the tumours were at higher risk of advanced stage and nodal involvement
[376].

Currently, it is not possible to recommend a particular type of urinary diversion.
However, most institutions prefer ileal orthotopic neobladders and ileal conduits, based on clinical
experience [377,378].
In selected patients, such as patients with a single kidney, uretero-cutaneostomy is surgically the
least burdensome type of diversion (LE: 3). Recommendations related to RC and urinary diversions are
listed in Section 7.5.

7.4.5.Morbidity and mortality

In three long-term studies, and one population-based cohort study, the
peri-operative mortality was reported as 1.2-3.2% at 30 days and 2.3-8.0% at 90 days [202,337,339,379,380].
In a large single-centre series, early complications (within three months of surgery) were seen in
58% of patients [337].
Late morbidity was usually linked to the type of urinary diversion (see also above) [340,381].
Early morbidity associated with RC for NMIBC (at high risk for disease progression) is similar and
no less than that associated with muscle-invasive tumours [382].
In general, lower morbidity and (peri-operative) mortality have been observed by surgeons and in
hospitals with a higher case load and therefore more experience [379,383-387].

If the
patient suffers from a complication at the time of discharge, the suffix “d” (for
‘disability’) is added to the respective grade of complication. This label indicates the
need for a follow-up to fully evaluate the complication.

1 A SR showed that
peri-operative blood transfusion (PBT) in patients who undergo RC correlates with increased overall
mortality, CSM and cancer recurrence. The authors hypothesised that this may be caused by the
suggested immunosuppressive effect of PBT. The foreign antigens in transfused blood induce immune
suppression, which may lead to tumour cell spread, tumour growth and reduced survival in already
immunosuppressed cancer patients. As other possible causes for this finding increased post-operative
infections and blood incompatibility were mentioned [389].
Buchner and co-workers showed similar results in a retrospective study. The five-year CSS decreased
in cases where intra-operative blood transfusion (CSS decreased from 67% to 48%) or post-operative
blood transfusion (CSS decreased from 63% to 48%) were given [390].

3 Hammond and
co-workers reviewed 20,762 cases of venous thromboembolism (VTE) after major surgery and found
cystectomy patients to have the second highest rate of VTE among all cancers studied [392].
These patients benefit from 30 days low-molecular-weight heparin prophylaxis. Subsequently, it was
demonstrated that BMI > 30 and non-urothelial BCs are independently associated with VTE after
cystectomy. In these patients extended (90 days) heparin prophylaxis should be considered [393].

7.4.6.Survival

According to a multi-institutional database of 888 consecutive patients undergoing
RC for BC, the five-year RFS rate was 58% and CSS was 66% [394].
External validation of post-operative nomograms for BC-specific mortality showed similar results,
with bladder-CSS of 62% [395].

Recurrence-free survival and OS in a large single-centre study of
1,054 patients was 68% and 66% at five years and 60% and 43%, at ten years, respectively [188].
However, the five-year RFS in node-positive patients who underwent cystectomy was considerably less
at 34-43% [187,396].
In a surgery-only study, the five-year RFS was 76% in patients with pT1 tumours, 74% for pT2, 52%
for pT3, and 36% for pT4 [188].

A trend analysis according to the five-year survival and mortality rates of BC in
the U.S. between 1973 and 2009 with a total of 148,315 BC patients, revealed increased
stage-specific five-year survival rates for all stages, except for metastatic disease [397].

7.4.7.Impact of hospital and surgeon volume on treatment outcomes

A SR was performed to assess the impact of hospital and/or surgeon volume on
peri-operative mortality and morbidity of RC [10].
Out of 1,078 publications screened a total of 31 papers were included in the review. Fifteen studies
reported on annual hospital volume only, five studies on surgeon volume only and eleven studies
reported on both. Primary outcome of the SR was peri-operative mortality. Hospitals performing more
RCs reported lower in-hospital, 30- and 90-day mortality in most publications. Also, the
complication rate appeared to be lower in higher-volume hospitals. However, due to differences in
baseline characteristics, subgroup definitions and statistical analyses among studies, a threshold
hospital volume associated with improved outcomes could not be defined.

7.4.8.Summary of evidence and guidelines for radical cystectomy and urinary diversion

There are data to support that
extended lymph node dissection (LND) (vs. standard or limited LND) improves survival after
RC.

3

Radical cystectomy in both
sexes must not include removal of the entire urethra in all cases, which may then serve as
the outlet for an orthotopic bladder substitution. The terminal ileum and colon are the
intestinal segments of choice for urinary diversion.

3

The type of urinary diversion
does not affect oncological outcome.

3

Laparoscopic cystectomy and
robotic-assisted laparoscopic cystectomy are feasible but still investigational. Current
best practice is open RC.

3

In patients aged > 80 years
with MIBC, cystectomy is an option.

3

Surgical outcome is influenced
by comorbidity, age, previous treatment for bladder cancer or other pelvic diseases, surgeon
and hospital volumes of cystectomy, and type of urinary diversion.

2

Surgical complications of
cystectomy and urinary diversion should be reported using a uniform grading system.
Currently, the best-adapted grading system for cystectomy is the Clavien grading system.

2

No conclusive evidence exists
as to the optimal extent of LND.

2a

Recommendations

Strength
rating

Do not delay radical
cystectomy (RC) for > 3 months as it increases the risk of progression and
cancer-specific mortality.

Strong

Before RC, fully
inform the patient about the benefits and potential risks of all possible alternatives. The
final decision should be based on a balanced discussion between the patient and the
surgeon.

Strong

Do not offer an
orthotopic bladder substitute diversion to patients who have a tumour in the urethra or at
the level of urethral dissection.

Strong

Pre-operative bowel
preparation is not mandatory. “Fast track” measurements may reduce the time to bowel
recovery.

7.5.Unresectable tumours

7.5.1.Palliative cystectomy for muscle-invasive bladder carcinoma

Locally advanced tumours (T4b, invading the pelvic or abdominal wall) may be
accompanied by several debilitating symptoms, including bleeding, pain, dysuria and urinary
obstruction. These patients are candidates for palliative treatments, such as palliative RT.
Palliative cystectomy with urinary diversion carries the greatest morbidity and should be considered
for symptom relief only if there are no other options [398-400].

Locally advanced MIBC can be associated with ureteral obstruction due to a
combination of mechanical blockage by the tumour and invasion of ureteral orifices by tumour cells.
In a series of 61 patients with obstructive uraemia, RC was not an option in 23 patients, and
obstruction was relieved using permanent nephrostomy tubes [401].
Another ten patients underwent palliative cystectomy, but local pelvic recurrence occurred in all
ten patients within the first year of follow-up. Another small study (n = 20) showed that primary
cystectomy for T4 BC was technically feasible and associated with a very tolerable therapy-related
morbidity and mortality [402].

7.5.2.Supportive care

7.5.2.1.Obstruction of the upper urinary tract

Unilateral (best kidney) or bilateral nephrostomy tubes provide the easiest
solution for UUT obstruction, but patients find the tubes inconvenient and prefer ureteral stenting,
however, stenting can be difficult to achieve.Stents must be regularly replaced and there is the
risk of stent obstruction or displacement. Another possible solution is a urinary diversion with, or
without, a palliative cystectomy.

7.5.2.2.Bleeding
and pain

In the case of bleeding, the patient must be screened first for coagulation
disorders or the patient’s use of anticoagulant drugs must be reviewed. Transurethral (laser)
coagulation may be difficult in a bladder full of tumour or with a bleeding tumour. Intravesical
rinsing of the bladder with 1% silver nitrate or 1-2% alum can be effective [403].
It can usually be done without any anaesthesia. The instillation of formalin (2.5-4% for 30 minutes)
is a more aggressive and painful procedure, requiring anaesthesia. Formalin instillation has a
higher risk of side-effects, e.g. bladder fibrosis, but is more likely to control the bleeding [403].
Vesicoureteral reflux should be excluded to prevent renal complications.

Radiation therapy is another common strategy for control of bleeding, and is also
used to control pain. An older study reported control of haematuria in 59% of patients and pain
control in 73% [404].
Irritative bladder and bowel complaints due to irradiation are possible, but are usually mild.
Non-conservative options are embolisation of specific arteries in the small pelvis, with success
rates as high as 90% [403].
Radical surgery is a last resort and includes cystectomy and diversion (see above Section 7.5.1).

7.6.Bladder-sparing treatments for localised disease

7.6.1.Transurethral resection of bladder tumour

Transurethral resection of bladder tumour alone in patients with muscle-invasive
bladder tumours is only possible as a therapeutic option if tumour growth is limited to the
superficial muscle layer and if re-staging biopsies are negative for residual (invasive) tumour [405].
In general, approximately 50% of patients will still have to undergo RC for recurrent MIBC with a
disease-specific mortality rate of up to 47% within this group [406].
A disease-free status at re-staging TURB appears to be crucial in making the decision not to perform
RC
[407,408].
A prospective study by Solsona et al., which included 133
patients with radical TURB and re-staging negative biopsies, reported a fifteen-year follow-up [408].
Thirty per cent had recurrent NMIBC and went on to intravesical therapy, and 30% (n = 40)
progressed, of which 27 died of BC. After five, ten, and fifteen years, the results showed CSS rates
of 81.9%, 79.5%, and 76.7%, respectively and PFS rates with an intact bladder of 75.5%, 64.9%, and
57.8%, respectively.

In conclusion, TURB alone should only be considered as a
therapeutic option for muscle-invasive disease after radical TURB, when the patient is unfit for
cystectomy, or refuses open surgery, or as part of a multimodality bladder-preserving approach.

7.6.1.1.Guideline for transurethral resection of
bladder tumour

Recommendation

Strength
rating

Do not offer
transurethral resection of bladder tumour alone as a curative treatment option as most
patients will not benefit.

Strong

7.6.2.External beam radiotherapy

Current RT techniques with soft-tissue matching result in superior bladder coverage
and a reduced integral dose to the surrounding tissues. The target dose for curative EBRT in BC is
64-66 Gy [409],
with a subsequent boost using external RT or interstitial RT. In a phase II study including 55
patients (median age 86) unfit for cystectomy or even daily RT, BC was treated with six-weekly doses
of 6 Gy [410].
Forty-eight patients completed EBRT with acceptable toxicity and 17% had showed local progression
after two years demonstrating good local control with this hypofractionated schedule.

The use of modern standard EBRT techniques results in major
related late morbidity of the urinary bladder or bowel in less than 5% of tumour-free patients [411].
Acute diarrhoea is reduced even more with intensity-modulated RT [412].
Important prognostic factors for outcome include response to EBRT, tumour size, hydronephrosis and
completeness of the initial TURB. Additional prognostic factors reported were age and stage [413].

With the use of modern EBRT techniques, efficacy and safely results seem to have
improved over time. A 2002 Cochrane analysis demonstrated that RC has an OS benefit compared to RT [398],
although this was not the case in a 2014 retrospective review using a propensity score analysis [399].
In a 2017 retrospective cohort study of U.S. National Cancer Data Base data, patients over 80 were
identified with cT2-4, N0-3, M0 BC, who were treated with curative EBRT (60-70 Gy, n = 739) or
concurrent chemoradiotherapy (n = 630) between 2004 and 2013 [414].
The two-year OS was 42% for EBRT vs. 56% for chemoradiotherapy (p < 0.001). For EBRT a higher RT
dose and a low stage were associated with improved OS.

In conclusion, although EBRT results seem to improve over time, EBRT alone does not
seem to be as effective as surgery or combination therapy (see Section 7.6.4). Factors that
influence outcome should be considered. However, EBRT can be an alternative treatment in patients
unfit for radical surgery, as it can be used to control bleeding.

7.6.2.1.Summary of evidence and guideline for external beam radiotherapy

Summary of evidence

LE

External beam radiotherapy
alone should only be considered as a therapeutic option when the patient is unfit for
cystectomy or as part of a multimodality bladder-preserving approach.

3

Radiotherapy can also be used
to stop bleeding from the tumour when local control cannot be achieved by transurethral
manipulation because of extensive local tumour growth.

3

Recommendation

Strength
rating

Do not offer
radiotherapy alone as primary therapy for localised bladder cancer.

Strong

7.6.3.Chemotherapy

Chemotherapy alone rarely produces durable complete remissions. In general, a
clinical complete response rate of up to 56% is reported in some series, which must be weighed
against a staging error of > 60% [415,416].
Response to chemotherapy is a prognostic factor for treatment outcome and eventual survival [417]
although it may be confounded by patient selection.

Several groups have reported the effect of chemotherapy on resectable tumours
(neoadjuvant approach), as well as unresectable primary tumours [210,225,418,419].
Neoadjuvant chemotherapy with two to three cycles of MVAC or CMV has led to a downstaging of the
primary tumour in different prospective series [210,225,418].

For highly selected patients, a bladder-conserving strategy with
TURB and systemic cisplatin-based chemotherapy, preferably with MVAC, may allow long-term survival
with intact bladder [417].
However, this approach cannot be recommended for routine use.

7.6.3.1.Summary of evidence and guideline for chemotherapy

Summary of evidence

LE

Complete and partial local
responses have been reported with cisplatin-based chemotherapy as primary therapy for
locally advanced tumours in highly selected patients.

2b

Recommendation

Strength
rating

Do not offer
chemotherapy alone as primary therapy for localised bladder cancer.

Strong

7.6.4.Multimodality bladder-preserving treatment

Multimodality treatment (MMT) or trimodality treatment combines TURB, chemotherapy
and radiation. The rationale to combine TURB with RT is to achieve local tumour control in the
bladder and adjacent nodes. The addition of systemic chemotherapy or other radiosensitisers
(mentioned below) is aimed at the potentiation of RT. Micrometastases are targeted by platinum-based
combination chemotherapy, for details see Section 7.2. The aim of MMT is to preserve the bladder and
QoL without compromising oncological outcome. There are no completed RCTs comparing the outcome of
MMT with RC, but MMT has been shown to be superior to RT alone [420,421].
Many of the reported series have differing characteristics as compared to the larger surgical
series, which typically have median ages in the mid to late 60s compared to mid-70s for some large
RT series (reviewed by James, et al. [420]).
In the case of MMT, two distinct patterns of care emerge: treatment aimed at patients fit for
cystectomy and treatment aimed at older, less fit patients. For the former category, MMT presents
selective bladder preservation. In that case, the initial step is a radical TURB, where as much
tumour as possible should be resected. This implies that proper patient selection (T2 tumours, no
CIS) is critical [422].
Even in the case of an initial presumed complete resection, a second TUR reveals tumour in > 50%
of patients and subsequently improves five-year OS in case of MMT [423].
For patients who are not candidates for cystectomy, less stringent criteria can be applied, though
extensive CIS and poor bladder function should both be regarded as strong contraindications.

A collaborative review has described the principles of MMT [424].
For radiation, two schedules are in common use worldwide: a split-dose format with interim
cystoscopy is used in the U.S. [421],
whilst single-phase treatment is more commonly used elsewhere [420].
A standard radiation schedule includes EBRT to the bladder and limited pelvic LNs with an initial
dose of 40 Gy, with a boost to the whole bladder of 54 Gy and a further tumour boost, with a total
dose of 64 Gy. In a small RCT, however, it was reported that leaving out elective pelvic nodal
irradiation did not compromise pelvic control rate, but significantly decreased the acute radiation
toxicity [425].

Different chemotherapy regimens have been used, but most evidence
exists for cisplatin [426]
and mitomycin C plus 5-FU [420].
In addition to these agents, other schedules have also been used, such as hypoxic cell sensitisation
with nicotinamide, carbogen and gemcitabine. To detect non-responders, which should be offered
salvage cystectomy, bladder biopsies should be performed after MMT.

Five-year CSS and OS rates vary between 50% to 82% and 36% to
74%, respectively, with salvage cystectomy rates of 10-30% [420,424,426,427].
The Boston group reported on their experience in 66 patients with variant histology treated with MMT
and found similar complete response, OS, DSS and salvage cystectomy rates as in UC [428].
The impact of MMT as compared to RC on long-term OS remains undefined. Two retrospective analyses of
the National Cancer Database from 2004-2013, with propensity score matching, compared RC to MMT.
Ritch et al. identified 6,606 RC and 1,773 MMT patients [429].
Worse survival was accompanied with higher age, comorbidity and tumour stage. After modelling, MMT
resulted in a lower mortality at 1 year (HR: 0.84, 95% CI: 0.74-0.96, p = 0.01). However, in years 2
and onwards, there was a signiﬁcant and persistent higher mortality after MMT (year 2: HR: 1.4, 95%
CI: 1.2-1.6, p < 0.001; and year 3 onwards: HR: 1.5, 95% CI: 1.2-1.8, p < 0.001). The second
analysis was based on a larger cohort, with 22,680 patients undergoing RC; 2,540 patients received
definitive EBRT and 1,489 MMT [430].
Survival after modelling was significantly better for RC compared to any EBRT, definitive EBRT and
MMT (HR: 1.4 [95% CI: 1.2-1.6]) at any point in time. On the other hand, a SR including 57 studies
and over 30,000 patients comparing RC and MMT, found improved ten-year OS and DSS for MMT, but for
the entire cohort OS and DSS between RC and MMT were not significantly different [431].
Complete response after MMT resulted in a significant better survival, as did downstaging after TUR
or NAC in case of RC.

There are data that major complication rates are similar for salvage and primary
cystectomy [432].
The majority of recurrences post-MMT are non invasive and can be managed conservatively [420].
A retrospective study showed QoL to be good after MMT and in most domains better than after
cystectomy, although prospective validations are needed [433].

A collaborative review came to the conclusion that data are
accumulating, suggesting that bladder preservation with MMT leads to acceptable outcomes and
therefore MMT may be considered a reasonable treatment option in well-selected patients as compared
to RC [424].
Multimodality bladder-preserving treatment should also be considered in all patients with a
contraindication for surgery, either a relative or absolute contraindication since the factors that
determine fitness for surgery and chemoradiotherapy differ.

There are no definitive data to support the benefit of using
neoadjuvant or adjuvant chemotherapy. Patient selection is critical in achieving good outcomes [424].

A bladder-preserving multimodality strategy requires very close multidisciplinary
cooperation, the importance of which was highlighted by a Canadian group [434].
In Ontario between 1994 and 2008 only 10% (370/3,759) of patients with cystectomy had a
pre-operative radiation oncology consultation, with high geographical variations. Independent
factors associated with this consultation included advanced age (p < 0.001), greater comorbidity
(p < 0.001) and earlier year of diagnosis (p < 0.001). A bladder-preserving multimodality
strategy also requires a high level of patient compliance. Even if a patient has shown a clinical
response to a multimodality bladder-preserving strategy, the bladder remains a potential source of
recurrence, hence long-term bladder monitoring is essential and patients should be counselled that
this will be required. A sub-analysis of two RTOG trials looked at complete response (T0) and near
complete response (Ta or Tis) after MMT [435].
After a median follow-up of 5.9 years 41/119 (35%) of patients experienced a bladder recurrence, and
fourteen required salvage cystectomy. There was no difference between complete and near-complete
responders. Non-muscle-invasive BC recurrences after complete response to MMT were reported in 25%
of patients by the Boston group, sometimes over a decade after initial treatment [436].
A NMIBC recurrence was associated with a lower DSS, although in properly selected patients,
intravesical BCG could avoid immediate salvage cystectomy.

7.6.4.1.Summary of evidence and guidelines for multimodality treatment

Summary of evidence

LE

In a highly selected patient
population, long-term survival rates of multimodality treatment are comparable to those of
early cystectomy.

2b

Recommendations

Strength
rating

Offer surgical
intervention or multimodality treatments (MMT) as primary curative therapeutic approaches
since they are more effective than radiotherapy alone.

Strong

Offer MMT as an
alternative to selected, well-informed and compliant patients, especially for whom
cystectomy is not an option.

Strong

7.7.Adjuvant therapy

7.7.1.Role of adjuvant platinum-based chemotherapy

Adjuvant chemotherapy after RC for patients with pT3/4 and/or LN positive (N+)
disease without clinically detectable metastases (M0) is still under debate [432,437]
and is infrequently used [206].

The general benefits of adjuvant chemotherapy include:

chemotherapy is administered after accurate pathological staging, therefore treatment in
patients at low risk for micrometastases is avoided;

no delay in definitive surgical treatment.

The drawbacks of adjuvant chemotherapy are:

assessment of in vivo chemosensitivity of the tumour is not
possible and overtreatment is an unavoidable problem;

delay or intolerability of chemotherapy, due to post-operative morbidity [438].

There is limited evidence from adequately conducted and accrued randomised phase
III trials in favour of the routine use of adjuvant chemotherapy [437,439-444].
An individual patient data meta-analysis [439]
of survival data from six RCTs of adjuvant chemotherapy [427,445-448]
included 491 patients (unpublished data from Otto et al., were
included in the analysis). All included trials suffered from significant methodological flaws
including small sample size (underpowered), incomplete accrual, use of inadequate statistical
methods and design flaws (irrelevant endpoints and failing to address salvage chemotherapy in case
of relapse or metastases) [437].
In these trials, three or four cycles of CMV, cisplatin, cyclophosphamide, and adriamycin (CISCA),
methotrexate, vinblastine, adriamycin or epirubicin, and cisplatin (MVA(E)C) and cisplatin and
methotrexate (CM) were used [449],
and one trial used cisplatin monotherapy [447].
These data were not convincing enough to give an unequivocal recommendation for the use of adjuvant
chemotherapy.

In 2014, this meta-analysis [440]
was updated with an additional three studies [441-443]
resulting in the inclusion of 945 patients from nine trials. None of the trials had fully accrued
and individual patient data were not used in the analysis [440].
For one trial only an abstract was available at the time of the meta-analysis [442],
and none of the included individual trials were significantly positive for OS in favour of adjuvant
chemotherapy. In two of the trials more modern chemotherapy regimens were used
(gemcitabine/cisplatin and paclitaxel/gemcitabine and cisplatin) [441,442].
The HR for OS was 0.77 and there was a trend towards an OS benefit when including all nine trials.
The effect was stronger for DFS (HR: 0.66; 95% CI: 0.48-0.92) and when stratified for the ratio of
nodal positivity (HR: 0.64; 95% CI: 0.45-0.91), which is caused by the heterogeneity in outcomes
observed between the included studies. After stratification of the studies by the ratio of node
positivity, no further heterogeneity was identified. The HR for DFS associated with adjuvant
cisplatin-based chemotherapy in studies with higher nodal involvement was 0.39 (95% CI: 0.28-0.54),
compared with 0.89 (95% CI: 0.69-1.15) in studies with less nodal involvement.

Furthermore, a large observational study including 5,653 patients
with pathological T3-4 and/or pathological node-positive BC, treated between 2003 and 2006
compared the effectiveness of adjuvant chemotherapy vs. observation. Twenty-three percent of
patients received adjuvant chemotherapy with a five-year OS of 37% for the adjuvant arm (HR: 0.70;
95% CI: 0.64-0.76), vs. 29.1% in the observation group [452].

From the currently available evidence it is still unclear whether immediate
adjuvant chemotherapy or chemotherapy at the time of relapse is superior, or if the two approaches
are equivalent with respect to the endpoint of OS. Cisplatin-based combination chemotherapy results
in long-term DFS, even in metastatic disease, mainly in patients with LN metastases only, and with a
good PS [453-455].
In the most recent meta-analysis, the positive role of adjuvant chemotherapy for BC has been
strengthened; however, still with a poor level of evidence [440].
Patients should be informed about potential chemotherapy options before RC, including neoadjuvant
and adjuvant chemotherapy, and the limited evidence for adjuvant chemotherapy.

7.7.2.Role of adjuvant immunotherapy

To evaluate the benefit of PD1/PD-L1 checkpoint inhibitors, a number of clinical
trials comparing checkpoint inhibitor monotherapy, including atezolizumab, nivolumab and
pembrolizumab, and any of these inhibitors against placebo, are ongoing.

7.7.3.Guidelines for adjuvant therapy

Recommendations

Strength
rating

Offer adjuvant
cisplatin-based combination chemotherapy to patients with pT3/4 and/or pN+ disease if no
neoadjuvant chemotherapy has been given.

Strong

Offer immunotherapy
with a checkpoint inhibitor only in a clinical trial setting.

Strong

7.8.Metastatic disease

7.8.1.Introduction

Approximately 50% of patients with muscle-invasive UC relapse after RC, depending
on the pathological stage of the primary tumour and the nodal status. Local recurrence accounts for
30% of relapses, whereas distant metastases are more common. Ten to fifteen percent of patients are
already metastatic at diagnosis [456].
Before the development of effective chemotherapy, patients with metastatic UC had a median survival
rarely exceeding three to six months [457].

7.8.1.1.Prognostic factors and treatment
decisions

Prognostic factors are crucial for assessing phase II study results and stratifying
phase III trials [458,459].
In a multivariate analysis, Karnofsky PS of < 80% and
presence of visceral metastases were independent prognostic factors of poor survival after treatment
with MVAC [459].
These prognostic factors have also been validated for newer combination chemotherapy regimens [460-462].

For patients refractory to, or progressing shortly after,
platinum-based combination chemotherapy, four prognostic groups have been established, based on
three adverse factors that have developed in patients treated with vinflunine, and that have been
validated in an independent data set: Hb < 10 g/dL; presence of liver metastases and ECOG PS
> 1 [463].

7.8.1.2.Comorbidity in metastatic disease

Comorbidity is defined as “the presence of one or more disease(s) in addition to an
index disease” (see Section 6.2.1). Comorbidity increases with age. However, chronological age does
not necessarily correlate with functional impairment. Different evaluation systems are being used to
screen patients as potentially fit or unfit for chemotherapy, but age alone should not be used to
base treatment selection on [464].

7.8.1.3.Definition - Not eligible for cisplatin
(unfit)

The EORTC conducted the first randomised phase II/III trial for UC patients who
were unfit for cisplatin chemotherapy [465].
The EORTC definitions were GFR < 60 mL/min and/or PS 2.

An international survey among BC experts [466]
was the basis for a consensus statement on how to classify patients unfit for cisplatin-based
chemotherapy. At least one of the following criteria has to be present: PS > 1; GFR < 60 mL/min; grade > 2 audiometric loss; peripheral neuropathy; and New
York Heart Association (NYHA) class III heart failure [467].

More than 50% of patients with UC are not eligible for cisplatin-based chemotherapy
[468-471].
Renal function assessment in UC is of utmost importance for treatment selection [468,472].
In case of doubt, measuring GFR with radioisotopes (99mTc DTPA or 51Cr-EDTA) is recommended.
Cisplatin has also been administered in patients with low GFR using different schedules. The
respective studies were mostly small phase I and II trials [473-476].
In one phase III trial the GFR cut off for cisplatin eligibility was > 50 mL/min [477].

7.8.2.Standard first-line chemotherapy for fit patients

Cisplatin-containing combination chemotherapy has been the standard of care since
the late 1980s demonstrating an OS of twelve to fourteen months in different series (for a review
see
[478]).
Methotrexate, vinblastine, adriamycin plus cisplatin (MVAC) and GC prolonged survival to up to 14.8
and 13.8 months, respectively, compared to monotherapy and older chemotherapy combinations. Neither
of the two combinations is superior to the other but equivalence has not been tested. Response rates
were 46% and 49% for MVAC and GC, respectively. The long-term survival results have confirmed the
efficacy of the two regimens [454].
The major difference between the above-mentioned combinations is toxicity. The lower toxicity of GC
[160]
has resulted in it becoming a new standard regimen [479].
Methotrexate, vinblastine, adriamycin plus cisplatin is better tolerated when combined with
granulocyte colony-stimulating factor (G-CSF) [479,480].

High-dose intensity MVAC (HD-MVAC) combined with G-CSF is less toxic and more
efficacious than standard MVAC in terms of dose density, complete response (CR), and two-year
survival rate. However, there is no significant difference in median survival between the two
regimens [481,482].
In general, all disease sites have been shown to respond to cisplatin-based combination
chemotherapy. A response rate of 66% and 77% with MVAC and HD-MVAC, respectively, has been reported
in retroperitoneal LNs vs. 29% and 33% at extranodal sites [481].
The disease sites also have an impact on long-term survival. In LN-only disease, 20.9% of patients
were alive at five years compared to only 6.8% of patients with visceral metastases [454].

Further intensification of treatment using paclitaxel, cisplatin and gemcitabine
(PCG) triple regimen did not result in a significant improvement in OS in the intent-to-treat (ITT)
population of a large randomised phase III trial, comparing PCG triple regimen to GC [483].
However, the overall response rate (ORR) was higher with the triple regimen (56% vs. 44%, p =
0.0031), and the trend for OS improvement in the ITT population (15.8 vs. 12.7 months; HR = 0.85, p
= 0.075) became significant in the eligible population. Adding paclitaxel to GC did not induce
additional major side effects. Grade 4 neutropenia was more common (35.8% vs. 20% for GC), as was
febrile neutropenia (13.2% vs. 4.3%), and the need for G-CSF was higher (17% vs. 11%).
Gemcitabine/cisplatin alone caused more grade 4 thrombocytopenia and thrombocytopenia-induced
bleeding (11.4% vs. 6.8%). Paclitaxel, cisplatin and gemcitabine is an additional option for
first-line treatment of UC.

7.8.3.Carboplatin-containing chemotherapys for fit patients

Carboplatin-containing chemotherapy is not equivalent to cisplatin combinations,
and should not be considered interchangeable or standard. Several randomised phase II trials of
carboplatin vs. cisplatin combination chemotherapy have produced lower CR rates and shorter OS for
the carboplatin arms [484].

7.8.4.Chemotherapy in patients unfit for cisplatin

Up to 50% of patients are ineligible for cisplatin-containing chemotherapy [467].
The first randomised phase II/III trial in this setting was conducted by the EORTC and compared
methotrexate/carboplatin/vinblastine (M-CAVI) and carboplatin/gemcitabine (GemCarbo) in patients
unfit for cisplatin. Both regimens were active. Severe acute toxicity was 13.6% in patients treated
with GemCarbo vs. 23% with M-CAVI, while the ORR was 42% for GemCarbo and 30% for M-CAVI. Further
analysis showed that in patients with PS 2 and impaired renal function, combination chemotherapy
provided limited benefit [465].
The ORR and severe acute toxicity were both 26% for the former group, and 20% and 24%, respectively,
for the latter group [465].
Phase III data have confirmed these results [462].

A recently published randomised, multinational phase II trial
(JASINT1) assessed the efficacy and tolerability profile of two vinflunine-based regimens
(vinflunine-gemcitabine vs. vinflunine-carboplatin). Both regimens showed equal ORR and OS with less
haematologic toxicity for the combination vinflunine-gemcitabine [485].

7.8.4.1.Non-platinum combination chemotherapy

Different combinations of gemcitabine and paclitaxel have been studied as first-
and second-line treatments. Apart from severe pulmonary toxicity with a weekly schedule of both
drugs, this combination is well tolerated and produces response rates between 38% and 60% in both
lines. Non-platinum combination chemotherapy has not been compared to standard cisplatin
chemotherapy in RCTs; therefore, it is not recommended for first-line use in cisplatin-eligible
patients [486-493].

7.8.4.2.Single-agent chemotherapy

Response rates to single-agent first-line chemotherapy vary. The most robust data
have shown a response rate of about 25% for first- and second-line gemcitabine in several phase II
trials [494,495].
Responses with single agents are usually short-lived, complete responses are rare and no long-term
DFS has been reported. The median survival in such patients is only six to nine months.

7.8.5.Second-line chemotherapy

Second-line chemotherapy data are highly variable and prognostic factors have been
established only recently (see Section 7.8.1.1) [463].
A reasonable strategy has been to re-challenge former cisplatin-sensitive patients if progression
occurred, at least six to twelve months after first-line cisplatin-based combination chemotherapy.
Second-line response rates of single agent treatment with paclitaxel (weekly), docetaxel,
nab-paclitaxel [496]
oxaliplatin, ifosfamide, topotecan, pemetrexed, lapatinib, gefitinib and bortezomib have ranged
between 0% and 28% in small phase II trials [494,497,498].
Gemcitabine had also shown good response rates in second-line use but most patients receive this
drug as part of their first-line treatment [493].

Paclitaxel/gemcitabine studies have shown response rates of
38-60%. No randomised phase III trial with an adequate comparator arm has been conducted to assess
the true value and OS benefit of this second-line combination [457,491,499].

Vinflunine, a novel third-generation vinca alkaloid, provided
promising results in phase II trials [500].
A randomised phase III trial compared vinflunine plus best supportive care (BSC) against BSC alone
in patients progressing after first-line treatment with platinum-containing combination chemotherapy
for metastatic disease [501].
The results showed a modest ORR (8.6%), a clinical benefit with a favourable safety profile and,
most importantly, a survival benefit in favour of vinflunine, which was statistically significant in
the eligible patient population (not in the ITT population). For second-line treatment of advanced
or metastatic UC this trial reached the highest level of evidence. Based on these findings,
vinflunine was approved in Europe (not in the U.S.) as the only second-line treatment option for
this indication. As immunotherapy with checkpoint inhibitors has recently been approved for
second-line treatment in metastatic UC, vinflunine should only be offered as second-line treatment
if checkpoint inhibitors or combination chemotherapy are not feasible. However, vinflunine may be
considered as third-line or subsequent treatment line option, although no randomised data exist for
this indication.

7.8.6.Low-volume disease and post-chemotherapy surgery

With cisplatin-containing combination chemotherapy, excellent response rates may be
obtained in patients with LN metastases only, good PS, and adequate renal function, including a high
number of CRs, with up to 20% of patients achieving long-term DFS [454,482,502,503].
The role of surgery of residual LNs after chemotherapy is still unclear. Although some studies
suggest a survival benefit and QoL improvement, the level of evidence supporting this practice is
mainly anecdotal [504-518].
Retrospective studies of post-chemotherapy surgery after partial or complete remission have
indicated that surgery may contribute to long-term DFS in selected patients [519-522].

Surgery for limited pulmonary metastases may also be considered
in highly selected cases. In the absence of data from RCTs, patients should be evaluated on an
individual basis and discussed by an interdisciplinary tumour board [522].

7.8.7.Treatment of patients with bone metastases

The prevalence of metastatic bone disease (MBD) in patients with
advanced/metastatic UC is 30-40% [523].
Skeletal complications due to MBD have a detrimental effect on pain and QoL and are also associated
with increased mortality [524].
Bisphosphonates such as zoledronic acid (ZA) reduce and delay skeletal-related events (SREs) due to
bone metastases by inhibiting bone resorption. In a small pilot study in patients with BC, SREs
caused by bone metastases were delayed [525].
Denosumab, a fully human monoclonal antibody that binds to and neutralises RANKL, was shown to be
non-inferior to ZA in preventing or delaying SREs in patients with solid tumours and advanced MBD,
including patients with UC [526].
Patients with MBD, irrespective of the cancer type, should be considered for bone-targeted treatment
[524].

Patients treated with ZA or denosumab should be informed about possible side
effects including osteonecrosis of the jaw and hypocalcaemia. Supplementation with calcium and
vitamin D is mandatory. Dosing regimens of ZA should follow regulatory recommendations and have to
be adjusted according to pre-existing medical conditions, especially renal function [527].
For denosumab, no dose adjustments are required for variations in renal function.

7.8.8.Role of immunotherapy

Immunomodulatory therapies using checkpoint inhibition, particularly with
antibodies directed against the programmed cell death-1 (PD-1) protein, its ligand (PD-L1) or the
cytotoxic T-lymphocyte-associated protein 4 (CTLA-4)-pathway have shown significant anti-tumour
activity with tolerable safety profiles and durable responses in patients with locally advanced and
metastatic UC. Trials currently investigate different immunotherapeutic agents either as monotherapy
or in combination with other immune-enhancing agents or chemotherapy in a range of different disease
settings. Pembrolizumab, nivolumab, atezolizumab, avelumab, and durvalumab have demonstrated similar
efficacy in patients progressing during, or after, standard platinum-based chemotherapy in phase I,
II and III trials.

7.8.8.1.First-line
immunotherapy for patients not eligible for standard cisplatin chemotherapy

A single arm phase II trial assessed the PD-1 inhibitor pembrolizumab in 370
patients with advanced or metastatic UC ineligible for cisplatin, showing an ORR of 29% and CR in 7%
of patients [528].
The PD-L1 inhibitor atezolizumab, a second agent was also evaluated in this patient population in a
two-cohort phase II trial (n = 119) including patients unfit for cisplatin (cohort 1). The ORR
was 29%; 9% of patients presented with a CR and median OS was 15.9 months [529].

The toxicity profile was favourable for pembrolizumab as well as
for atezolizumab. Since 2017 both drugs are U.S. Food and Drug Administration (FDA) and European
Medicines Agency approved for first-line treatment in cisplatin-ineligible patients. Late 2018 the
FDA issued a warning that patients with negative PD-L1 status (based on immunohistochemical
staining) might have an impaired outcome when treated with first-line immunotherapy. This warning
was based on preliminary results from ongoing phase III trials with pembrolizumab and atezolizumab.
However, no data from these studies are, as yet, in the public domain.

7.8.8.2.Second-line immunotherapy for platinum-pre-treated patients

Pembrolizumab, a PD-1 inhibitor, was the first agent that showed significant OS
benefit in patients progressing during, or after, platinum-based first-line chemotherapy. Based on
the results of a phase III trial the agent was approved in 2017. In the trial, patients (n =
542) were randomised to receive either pembrolizumab monotherapy, or chemotherapy (either
paclitaxel, docetaxel or vinflunine). The median OS in the pembrolizumab arm was 10.3 months (95%
CI: 8.0-11.8) vs. 7.4 months (95% CI: 6.1-8.3) for the chemotherapy arm (HR for death, 0.73; 95% CI:
0.59-0.91, p = 0.002) independent of PD-L1 expression levels [530].

Atezolizumab was the first PD-L1 inhibitor approved by the FDA (May 2016) for
patients progressing during, or after, previous platinum-based chemotherapy. In a phase II cohort
study including 310 patients, the objective response rate was 15%, independent of the expression of
PD-L1. Progression-free survival was 2.1 and OS was 7.9 months. According to the expression level of
PD-L1 numbers for response rate, PFS and OS were greater in patients with high expression, but
responses occurred also in patients with no expression of PD-L1. The toxicity profile of
atezolizumab was favourable [531,532].
The results of the phase III trial (IMvigor211) comparing atezolizumab with second-line chemotherapy
were recently published [533].
The trial did not meet its first endpoint of improved OS for patients with high PD-L1 expression (IC
score 2/3) but OS was significantly improved in the ITT population.

In 2017, nivolumab, another PD-1/PD-L1 inhibitor was approved based on the results
of a single-arm phase II trial (CheckMate 275), enrolling 270 patients. The first endpoint was
ORR. Patients were stratified by their PD-L1 expression (> 5% vs. < 5%). Objective response
rate was 19.6%, and OS was 8.74 months for the entire group [534].

Based on results of phase I/II and phase Ib trials, two
additional PD-1/PD-L1 inhibitors, durvalumab and avelumab are currently only approved for this
indication in the United States [535-537].

Data show that in responders, PD-1/PD-L1 inhibitors not only produce durable
responses but also offer a superior survival benefit as compared to standard chemotherapy
regimens.

7.8.9.Summary of evidence and guidelines for metastatic disease

Summary of evidence

LE

In a first-line setting,
performance status (PS) and the presence or absence of visceral metastases are independent
prognostic factors for survival.

Non-platinum combination
chemotherapy has not been tested against standard chemotherapy in patients who are fit or
unfit for cisplatin combination chemotherapy.

4

There is no defined standard
chemotherapy for unfit patients with advanced or metastatic urothelial cancer (UC).

2b

Post-chemotherapy surgery
after partial or complete response may contribute to long-term disease-free survival in
selected patients.

3

Zoledronic acid and denosumab
have been approved for supportive treatment in case of bone metastases of all cancer types
including UC, because they reduce and delay skeletal related events.

1b

PD-1 inhibitor pembrolizumab
has been approved for patients that have progressed during or after previous platinum-based
chemotherapy based on the results of a phase III trial.

1b

PD-L1 inhibitor atezolizumab
has been FDA approved for patients that have progressed during or after previous
platinum-based chemotherapy based on the results of a phase II trial.

2a

PD-1 inhibitor nivolumab has
been approved for patients that have progressed during or after previous platinum-based
chemotherapy based on the results of a phase II trial.

2a

PD-1 inhibitor pembrolizumab
has been approved for patients with advanced or metastatic urothelial cancer ineligible for
cisplatin-based first-line chemotherapy based on the results of a phase II trial but use of
pembrolizumab is restricted to PD-L1 positive patients.

2a

PD-L1 inhibitor atezolizumab
has been approved for patients with advanced or metastatic urothelial cancer ineligible for
cisplatin-based first-line chemotherapy based on the results of a phase II trial but use of
atezolizumab is restricted to PD-L1 positive patients.

2a

Recommendations

Strength
rating

First-line treatment for cisplatin-eligible patients

Use
cisplatin-containing combination chemotherapy with GC, MVAC, preferably with G-CSF, HD-MVAC
with G-CSF or PCG.

Offer zoledronic acid
or denosumab for supportive treatment in case of bone metastases.

Weak

Only offer vinflunine
to patients for metastatic disease as second-line treatment if immunotherapy or combination
chemotherapy is not feasible. Alternatively, offer vinflunine as third- or subsequent
treatment line.

7.8.10.Biomarkers

Modest disease control rates with sporadic marked responses in some patients with
UC have led to the investigation of biomarkers for assessment of post-operative prognosis and the
potential value of peri-operative chemotherapy, and as predictors of response to chemotherapy or its
monitoring. Most biomarkers are associated with tumour angiogenesis [538].
Small studies, usually retrospective, have investigated microvessel density, altered p53 tumour
expression [538],
serum vascular endothelial growth factor [539],
urinary and tissue basic fibroblast growth factor [540],
urinary (wild-type and mutant) and tissue fibroblast growth factor receptor-3 [541],
and more recently, thrombospondin-1 [542],
circulating tumour cells [543,544],
and multidrug resistance gene expression [545].
Although a few biomarkers have shown potential, as yet, there is insufficient evidence to support
their routine clinical use (LE: 3).

7.9.Quality of life

7.9.1.Introduction

The evaluation of HRQoL considers physical, psychological, emotional and social
functioning. The impact of BC on HRQoL was recently reported in a population-based study using the
SEER registry, including a total of 535 BC patients (458 with non-invasive disease and 77 with
invasive disease) older than 65 years and 2,770 matched non-cancer controls. The authors concluded
that BC patients experienced statistically significant declined HRQoL in all domains. In invasive
BC, particularly physical and social functioning were affected [546].

Several questionnaires have been validated for assessing HRQoL in
patients with BC, including FACT (Functional Assessment of Cancer Therapy)-G [547],
EORTC QLQ-C30 [548],
EORTC QLQ-BLM (MIBC module) [549],
and SF (Short Form)-36 [550,551]
and recently the BCI questionnaire specifically designed and validated for BC patients [552].

A psychometric test, such as the FACT-BL, should be used for
recording BC morbidity. New intensive interviewing techniques have added valuable information to our
knowledge of HRQoL, which greatly depends on patients’ individual preferences [553].

7.9.2.Radical cystectomy and urinary diversion

Two recent SRs focused on HRQoL after RC [554,555]
and one SR, based on 18 studies (n = 1,553), showed a slight, but not significant, improvement of
QoL in patients with an orthotopic diversion [554].
However, analysing only the studies comparing exclusively ileal conduit vs. ileal orthotopic
neobladder, the advantage in QoL of the latter group was significant. Another SR, based on 29
studies (n = 3,754), showed no difference in overall QoL between continent and incontinent diversion
[555].
Subgroup analysis demonstrated greater improvement in physical health for incontinent compared to
continent diversions (p = 0.002), but no differences in mental health (p = 0.35) or social health (p
= 0.81). However, patients with a neobladder demonstrated superior emotional function and body image
[555-557].

Clifford and co-workers prospectively evaluated continence
outcomes in male patients undergoing orthotopic neobladder diversion [558].
Day-time continence increased from 59% at less than three months post-operatively to 92% after 12 to
18 months. Night-time continence increased from 28% at less than three months post-operatively to
51% after 18 to 36 months. Also of interest is the urinary bother in female neobladder. Bartsch and
co-workers found in 56 female patients day-time and night-time continence rates of 70.4% and 64.8%,
respectively. Thirty-five patients (62.5%) performed clean intermittent catheterisation, which is
much worse when compared to male neobladder patients. Moreover, patients with non-organ-confined
disease (p = 0.04) and patients with a college degree (p = 0.001) showed worse outcomes on
HRQoL scores [559].

Altogether, HRQoL outcomes are most likely a result of good
patient selection. An older, more isolated, patient is probably better served with an ileal conduit,
whereas a younger patient with a likely higher level of interest in body image and sexuality is
better off with an orthotopic diversion. The patient’s choice is the key to the selection of
reconstruction method [555].

7.9.3.Bladder sparing trimodality therapy

A cross-sectional bi-institutional study found in multivariable analysis that
patients who received trimodality therapy (n = 64) had higher physical-, social-, emotional- and
cognitive functioning, better general QoL, sexual function and body image than patients after RC (n
= 109). However, urinary symptom scores were similar [433].
To draw valid conclusions, prospective studies are needed.

7.9.4.Non-curative or metastatic bladder cancer

In non-curative or metastatic BC, HRQoL is reduced because of associated
micturition problems, bleeding, pain and therefore disturbance of social and sexual life [560].
There is limited literature describing HRQoL in BC patients receiving palliative care [561],
but there are reports of bladder-related symptoms relieved by palliative surgery [402],
RT
[562],
and/or chemotherapy [563].

7.9.5.Summary of evidence and recommendations for health-related quality of life

Summary of evidence

LE

Compared to non-cancer
controls, the diagnosis and treatment of bladder cancer has a negative impact on HRQoL.

2a

There is no difference in
overall QoL between patients with continent or incontinent diversion.

1a

In most patient groups
studied, the overall HRQoL after cystectomy remains good, irrespective of the type of
urinary diversion used.

2b

Important determinants of
(subjective) quality of life are a patient’s personality, coping style and social
support.

3

Recommendations

Strength
rating

Use validated
questionnaires to assess health-related quality of life in patients with MIBC.

Provide clear and
exhaustive information on all potential benefits and side-effects, allowing patients to make
informed decisions. Encourage patients to actively participate in the decision-making
process.

Strong

8.FOLLOW-UP

8.1.Follow-up in muscle invasive bladder cancer

An appropriate schedule for disease monitoring should be based on natural timing of
recurrence; probability and site of recurrence; functional monitoring after urinary diversion and
the potential available management options [564].

Nomograms on CSS following RC have been developed and externally
validated, but their wider use cannot be recommended until further data become available [565,566].

Current surveillance protocols are based on patterns of
recurrence drawn from retrospective series only. Combining this data is not possible since most
retrospective studies use different follow-up regimens and imaging techniques. Additionally, reports
of asymptomatic recurrences diagnosed during routine oncological follow-up, and results from
retrospective studies are contradictory [567-569].
From the Volkmer B, et al. series of 1,270 RC patients, no
differences in OS were observed between asymptomatic and symptomatic recurrences [568].
Conversely, in the Giannarini, et al. series of 479 patients;
those with recurrences detected during routine follow-up (especially in the lungs) and with
secondary urothelial tumours as the site of recurrence, had a slightly higher survival probability [567].
Boorjian, et al. included 1,599 RC patients in their series,
with 77% symptomatic recurrences. On multivariate analysis, patients who were symptomatic at
recurrence had a 60% increased risk of death as compared to asymptomatic patients [569].

However, at this time, no data from prospective trials
demonstrating the potential benefit of early detection of recurrent disease, and its impact on OS,
are available [570].
For details see Section 7.6.4.

8.2.Site of recurrence

8.2.1.Local recurrence

Local recurrence takes place in the soft tissues of the original surgical site or
in LNs. Contemporary cystectomy has a 5-15% probability of pelvic recurrence which usually occurs
during the first 24 months, most often within six to eighteen months after surgery. However, late
recurrences can occur up to five years after RC. Risk factors described are pathological stage, LNs,
positive margins, extent of LND and peri-operative chemotherapy [571].

Patients generally have a poor prognosis after pelvic recurrence.
Even with treatment, median survival ranges from four to eight months following diagnosis.
Definitive therapy can prolong survival, but mostly provides significant palliation of symptoms.
Multimodality management generally involves a combination of chemotherapy, radiation and surgery [570].

8.2.2.Distant recurrence

Distant recurrence is seen in up to 50% of patients treated with RC for MIBC. As
with local recurrence, pathological stage and nodal involvement are risk factors [572].
Systemic recurrence is more common in locally advanced disease (pT3/4), ranging from 32 to 62%, and
in patients with LN involvement (range 52–70%) [573].

The most likely sites for distant recurrence are LNs, lungs,
liver and bone. Nearly 90% of distant recurrences appear within the first three years after RC,
mainly in the first two years, although late recurrence has been described after more than 10 years.
Median survival of patients with progressive disease treated with platinum-based chemotherapy is
9-26 months [574-576].
However, longer survival (28-33% at five years) has been reported in patients with minimal
metastatic disease undergoing multimodality management, including metastasectomy [505,513].

8.2.3.Urothelial recurrences

After RC, the incidence of new urethral tumours was 4.4% (1.3-13.7%). Risk factors
for secondary urethral tumours are urethral malignancy in the prostatic urethra/prostate and bladder
neck (in women). Orthotopic neobladder was associated with a significant lower risk of urethral
tumours after RC (OR: 0.44) [577].

There is limited data, and agreement, about urethral follow-up, with some authors
recommending routine surveillance with urethral wash and urine cytology and others doubting the need
for routine urethral surveillance. However, there is a significant survival advantage in men with
urethral recurrence diagnosed asymptomatically vs. symptomatically, so follow-up of the male urethra
is indicated in patients at risk of urethral recurrence [570].
Treatment is influenced by local stage and grade of urethral occurrence. In urethral CIS, BCG
instillations have success rates of 83% [578].
In invasive disease, urethrectomy should be performed if the urethra is the only site of disease and
in case of distant disease systemic chemotherapy is indicated [4].

Upper urinary tract urothelial carcinomas occur in 4-10% of cases and represent the
most common sites of late recurrence (three-year DFS following RC) [579].
Median OS is 10-55 months, and 60-67% of patients die of metastatic disease [570].
A recent meta-analysis found that 38% of UTUC recurrence was diagnosed by follow-up investigations,
whereas in the remaining 62%, diagnosis was based on symptoms. When urine cytology was used during
surveillance, the rate of primary detection was 7% vs. 29.6% with UUT imaging. The meta-analysis
concluded that patients with non-invasive cancer are twice as likely to have UTUC as patients with
invasive disease [561].
Multifocality increases the risk of recurrence by threefold, while positive ureteral or urethral
margins increase the risk by sevenfold. Radical nephro-ureterectomy can prolong survival [580].

8.3.Time schedule for surveillance

Although, based on low level of evidence, some follow-up schedules have been
suggested, guided by the principle that recurrences tend to occur within the first years following
initial treatment. A schedule suggested by the EAU Guidelines Panel includes a CT scan (every 6
months) until the third year, followed by annual imaging thereafter [4].
Patients with multifocal disease, NMIBC with CIS or positive ureteral margins are at higher risk of
developing UTUC, which can develop late (> three years). In those cases, monitoring of the UUT is
mandatory during follow-up. Computed tomography is to be used for imaging of the UUT [581].

The exact time to stop follow-up is not well known and recently a risk-adapted
schedule has been proposed, based on the interaction between recurrence risk and competing health
factors that could lead to individualised recommendations and may increase recurrence detection.
Elderly and very low-risk patients (those with NMIBC or pT0 disease at final cystectomy report)
showed a higher competing risk of non-BC mortality when compared with their level of BC recurrence
risk. On the other hand, patients with locally advanced disease or LN involvement are at a higher
risk of recurrence for more than 20 years [582].
However, this model has not been validated and does not incorporate several risk factors related to
non-BC mortality. Furthermore, the prognostic implications of the different sites of recurrence
should be considered. Local and systemic recurrences have a poor prognosis and early detection of
the disease will not influence survival [583].
Despite this, the rationale for a risk-adapted schedule for BC surveillance appears to be promising
and deserves further investigation.

8.4.Follow-up of functional outcomes and complications

Apart from oncological surveillance, patients with a urinary diversion need
functional follow-up. Complications related to urinary diversion are detected in 45% of patients
during the first five years of follow-up. This rate increases over time, and exceeds 54% after
fifteen years follow-up. Therefore, long-term follow-up of functional outcomes is desirable [570].

The functional complications are diverse and include: vitamin B12 deficiency,
metabolic acidosis, worsening of renal function, urinary infections, urolithiasis, stenosis of
uretero-intestinal anastomosis, stoma complications in patients with ileal conduit, neobladder
continence problems, and emptying dysfunction [570].
Especially in women approximately two-thirds need to catheterise their neobladder, while almost 45%
do not void spontaneously at all [559].
Recently a 21% increased risk of fractures was also described as compared to no RC, due to chronic
metabolic acidosis and subsequent long-term bone loss [583].

8.5.Summary of evidence and recommendations for specific
recurrence sites

Site of
recurrence

Summary of
evidence

LE

Recommendation

Strength
rating

Local recurrence

Poor prognosis.

Treatment should be individualised depending on the local
extent of tumour.

2b

Offer radiotherapy,
chemotherapy and possibly surgery as options for treatment, either alone or in
combination.

Strong

Distant
recurrence

Poor prognosis.

2b

Offer chemotherapy as
the first option, and consider metastasectomy in case of unique metastasis site.

147.Paleri, V., et al.
Applicability of the adult comorbidity evaluation - 27 and the Charlson indexes to assess
comorbidity by refs extraction in a cohort of United Kingdom patients with head and neck cancer: a
retrospective study. J Laryngol Otol, 2002. 116: 200.

361.Simon, J. Ectopia Vesicae
(Absence of the anterior walls of the Bladder and the pubic abdominal parietes) Operation for
directing the orifices of the ureteres into the rectum, temporary success) JAMA 1911. 1911: 398. [No
abstract available].

548.Aaronson, N.K., et al. The
European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for
use in international clinical trials in oncology. J Natl Cancer Inst, 1993. 85: 365.

This guidelines document was developed with the financial support
of the European Association of Urology. No external sources of funding and support have been involved. The EAU is
a non-profit organisation and funding is limited to administrative assistance and travel and meeting
expenses. No honoraria or other reimbursements have been provided.

11.CITATION INFORMATION

The format in which to cite the EAU Guidelines will vary depending on the style
guide of the journal in which the citation appears. Accordingly, the number of authors or whether, for instance, to
include the publisher, location, or an ISBN number may vary.

The compilation of the complete Guidelines should be referenced as: EAU Guidelines. Edn. presented at the EAU Annual Congress Barcelona 2019.
ISBN 978-94-92671-04-2.